Press release

HSE publishes wider review by independent safeguarding expert Jackie McIlroy on HSE safeguarding policies and procedures following published review of Emily case

The HSE today (Thursday, 20 June 2024) published the report of a high-level review of HSE policy, procedures, structures and options for the future of safeguarding across all settings.

The Review, which was commissioned by HSE CEO Bernard Gloster, was undertaken by independent safeguarding expert Jackie McIlroy.

In July last year, following the publication of the two separate investigations undertaken in the aftermath of a serious sexual assault on a resident (pseudonym 'Emily') at a HSE community nursing unit in April 2020, the HSE CEO requested an independent expert, Jackie McIlroy, to undertake two pieces of important work.

The first was to review the initial investigations carried out in the aftermath of the serious assault on Emily, and advise him, based on that review, if a further examination of individual records and the community nursing unit concerned was required to identify past harm. The report of this element was published by the HSE in September 2023 and work continues to implement its recommendations. The HSE has assembled a dedicated team to implement the recommendations of the September 2023 report. The team are currently reviewing cases on a phased basis and ensuring good ongoing communication with families. The logistics of identifying and contacting families of former residents is complex, and this work is ongoing. The CEO has asked Jackie McIlroy to assess progress against her 2023 recommendations by September of this year.

The second element undertaken by Jackie McIlroy was a wider review of safeguarding in the HSE and today the HSE is publishing the findings of this review.

Commenting HSE CEO Bernard Gloster said, “I wish to once again, on behalf of the HSE offer my deepest apologies to Emily’s family for the trauma she and they endured while she was in our care. I have met with them on a number of occasions and conveyed directly to them how sorry I am on behalf of the HSE for how she was failed. I would also like to remind all commentators that arising from the trial in this case there is an order prohibiting the identification of Emily and of the nursing home concerned. These orders are important to protect the privacy of Emily’s family.

“In July last year, I requested Jackie McIlroy to review the HSE’s safeguarding policy, procedures and structures, recognising the HSE’s role in safeguarding in both community and alternative care settings for adults. I wanted to get a better understanding of the wider issues relating to safeguarding and possible options for its future development. I am today publishing the outcome of this process and I want to thank Jackie McIlroy for her excellent and insightful work. I know she consulted widely over the last year, seeking the views of those who have experienced safeguarding services, families, staff, educators, professional bodies, among many more”.

In the report published today, Jackie McIlroy notes that there is broad consensus among all those she engaged with for the need for a transformation change in the way adult safeguarding is delivered and the system is organised. It is her view that the procedures currently in place are outdated and that there is need for cultural change. While she acknowledges that most managers work tirelessly and there are many examples of excellent care she states that too often she heard acceptance of poor quality care, defensive practice, and tolerance of abusive behaviours.

Ms McIlroy outlines four key actions supported by detailed recommendations now required in order to address the issues she has identified in her Review. These are;

  • embedding a safeguarding culture
  • increasing the visibility of safeguarding
  • supporting a strong change management process
  • embedding a culture of learning and improvement.

The HSE has now commenced a process to implement these recommendations and enable the development culture and practice across the HSE that places safeguarding at the centre of the services we provide.

Bernard Gloster added:

“I fully acknowledge we have much work to do to further develop and improve our safeguarding services. Our staff will be critical to this transformation and it is important to acknowledge that Jackie McIlroy highlights the appetite amongst our staff for change and improvement. Safeguarding is part of everyone’s job and I know the many excellent staff in the HSE will grasp this opportunity to transform and ensure we do all we can to protect vulnerable adults in our care. I am determined to ensure a completely new approach and structure to safeguarding in the HSE and a critical part of that change will be the imminent appointment, for the first time, of a Chief Social Worker. This new post will ensure leadership at the highest level in the organisation.

We must ensure a safe environment for those in our care and instil a culture which promotes openness and a willingness to highlight and call out practice and behaviours that are defensive at best and damaging at worst. I know that colleagues across the HSE are committed to this and I look fward to working with them in partnership with those who use our services over the coming weeks and months to make these critical changes.

I welcome the recent public consultation by the Department of Health on policy proposals for adult safeguarding across the health and social care sector and the Law Reform Commission’s report to inform wider developments beyond the HSE and all of this will ultimately lead to an increasingly safe place for adults who find themselves in vulnerable situations.”

Moving Forward: Adult Safeguarding in the Health Service Executive (PDF, 804 KB, 64 pages)

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