My question is in a similar vein to that of Deputy Catherine Murphy. I was shocked, as everybody was, to read the news that came out yesterday regarding yet another failure of HSE management in the north-west region. Recent correspondence from HIQA expressed concerns regarding a residential disability centre for adults in Donegal, where a resident accessed child sexual exploitation material on three separate occasions in 2016, 2017 and 2021. The HIQA report states that the HSE has repeatedly "failed to demonstrate fitness" to safeguard residents with disabilities in its centres.

It is important to note that the only reason we know of this incident, and of HIQA correspondence, is due to a leak. This is completely unacceptable and shows the ultimate problem here. It was the same case with the Brandon report, which was another example of complete failure of HSE management. The only reason this report came to light was that the Minister of State at the Department of Health, Deputy Anne Rabbitte, and I continued to press the HSE regarding it. The fact that a Minister of State had to continuously press the HSE in the first place just to get a copy of the Brandon report is extremely concerning and I ask the Taoiseach to consider this. To date, the Brandon report has still not been published, despite the families’ wish to see the full report, and we are again relying on leaks for information. Something needs to change here. When discussing the Brandon report last year, I asked how we can be sure this will not happen again, how we can instil trust in HSE management and, in the case of failures occurring again, how we can ensure we are informed of them. Sadly, months later we are again facing a similar situation and, again, the only reason we know about it is through leaks. The Taoiseach needs to put people’s minds at ease. We have to know that this will not happen again and that if it does, at the very least, we have to know about it.

A pattern of failure seems to be emerging among HSE management. We need an investigation into HSE management in the community healthcare organisation, CHO, 1 area, but we also need an investigation into this community healthcare organisation’s relationship nationally. That is a key part of this issue. There are serious concerns about how residential centres are currently being managed in Donegal, in addition to Cavan, Leitrim, Sligo and Monaghan, but I also have concerns regarding HSE management nationally and how the CHOs relate to national management. We also need to address problems with HIQA. I have concerns regarding its processes and I am wary of placing all the scrutiny on the HSE without recognising HIQA's role.

One way or another we urgently need an investigation into HSE management in CHO 1 and nationally. We need to know how management is being held accountable and how we can know that this will not happen again. Will the Taoiseach ensure that necessary and timely investigations into HSE management take place, following the ongoing patterns of failure occurring in our residential centres?

I thank the Deputy for raising these issues, which are very serious and are taken very seriously by the Government. As the Deputy said, the Minister of State, Deputy Rabbitte, has worked with him in respect of the Brandon report, which is a shocking and very disturbing report. What happened in that instance has caused enormous distress and hurt to the families involved. A national independent review has been commissioned by the HSE to carry out a review of abuse allegations at a HSE-provided residential service for adults with a disability.

In respect of the advice, the Minister of State sought the Attorney General's advice regarding the publication of the full Brandon report. As the Deputy knows, the HSE published the executive summary of that report last December. The advice received was that it is a matter for the HSE and the Minister of State may not direct the HSE to publish the report. The Garda is still completing its work and has advised the HSE against publication. The HSE, as the body responsible for publication, has determined that the report should not be published in full, but we are not finished with that yet. We will continue to pursue that because full transparency is required but, at the same time, we do not want to imperil or undermine any potential investigation the Garda may pursue regarding this.

In respect of the CHO 1 situation, HIQA advised the Minister for Health, Deputy Stephen Donnelly, and the Minister of State in December that the chief inspector had concerns about the ongoing governance of social care in CHO 1, including, as the Deputy outlined, a serious adult and child safeguarding concern. HIQA conducted unannounced inspections of all HIQA-designated centres for people with disabilities in Donegal, except those that had been inspected since September 2021. Preliminary feedback on the inspections has been provided to the HSE. HIQA's report on the inspections is expected shortly. I am advised, however, no issues were identified that have not been responded to appropriately, but we have to see the full report of those inspections. There are concerns, which the Minister is pursuing further, about the broader area of establishing the response and capacity of the CHO 1 area in respect of senior management there and how it is handling cases, some of which date back to the management of cases in 2016 and 2017. Terms of reference have been drawn up regarding that particular exercise.

More generally, the Deputy raised the issue of the HSE's nationwide response to matters of this kind. In the first instance, the HSE has a national framework in which there has to be full disclosure on issues such as this. There are clear benchmarks against which it needs to be judged in fulfilling those objectives.

On the CHO 1 issue, the Morris tribunal report covered the actions of the Garda. At the time, official Ireland wanted to make sure this issue stayed in Donegal. That was where it was seen to be, but we know that was not the case. We will end up in the same situation regarding this. That is why CHO 1's relationship, nationally, with HSE management also needs to be investigated.

On the Brandon report specifically, the Minister of State said she cannot publish it, which is fair enough, but the HSE can. That is a problem. The HSE is a law unto itself here. It works for us. We do not work for it. The HSE works for the Irish people. It is supposed to represent the Irish people not the other way around. It seems it is the other way around when we are dealing with the HSE. The Garda Síochána has completed its investigation in regard to the Brandon report so it cannot be held up as an excuse by the HSE.

We need an investigation. The most recent revelations took place after the Brandon report was published, such that management had not changed. We need to make sure that investigation takes place. We need to make sure that people have a fair hearing at all stages.

Again, I thank the Deputy for raising the issue. I hear what he is saying in respect of the publication of the Brandon report in full. As I said, the matter is not closed from the Government's perspective. We do not want to undermine any disciplinary issues or any other issues that may arise out of this.

There is nothing happening.

I am just making the point that it is not closed. We are not finished with this yet because it is a very serious case and a very serious issue. Speaking more generally, there has to be balance here. To return to the previous question, our existing agencies have to be able to do the work. Increasingly, almost daily now, it is an independent review for this and an independent review for that, where we have existing statutory agencies which are meant to be doing that work.

That has to tell you there is something wrong.

Hear me out. We have the Garda Síochána Ombudsman Commission, GSOC, in respect of the Garda-----

There is something wrong.

No. Into the future, we are going to have make sure that agencies such as HIQA and GSOC do their work like all of the other bodies that are there to regulate and to enforce regulation, otherwise we will have commissions being established every two months, with all of the implications that that brings with it. The Deputy will be aware that there are commissions of inquiry still going on six years later. There are issues that we need to look at collectively as an Oireachtas.