The opening in 2008 of Ard Greíne Court, a campus of seven bungalows for up to 40 intellectually disabled adults, in Stranorlar, Co Donegal, was greeted with delight by the families of those who would live there.
The event marked a significant step for disability services in the region as the Health Service Executive moved to bring intellectually disabled adults out of congregated settings and into their communities.
A total of 36 residents of the Seán O’Hare unit in nearby St Joseph’s hospital, some of who had lived there since the 1990s, would move to “normal” houses, not institutional-style living.
“I remember the good mood the day of its official opening,” recalls the brother of a severely disabled, non-verbal man, “Peter” (not his real name) who would move into House 1. “Everyone was delighted, it seemed a huge improvement. There was tea and coffee. It was a lovely summer’s day, tables were out.”
He looks back at that day now with hurt, disappointment and anger.
When the families of Ard Greíne ’s intellectually disabled residents were contacted by its management in the weeks before Christmas 2018, and told senior HSE officials wanted to meet them to discuss “a serious issue”, many were worried.
Some feared their loved ones were seriously ill, others that they would have to leave the campus, that it may be closing. Instead, the news was very different, and darker than any had imagined.
In prearranged visits to their homes, they were met by Frank Morrison, head of the HSE's social care services in Community Health Organisation 1 (CHO 1) which covers Donegal, and Jacinta Lyons, disability services manager.
They were told a “look back” review, commissioned by the CHO’s manager in 2016, had established their loved ones had been subjected to prolonged sexual abuse by another resident, since as early as 2003. Morrison and Lyons offered them the HSE’s apologies and provided phone numbers for support.
They were so “floored” and “shocked” by this news they could hardly process it, not knowing what to ask. “We had no inkling at all that anything like that had been happening,” says the brother of one victim “Colm” (not his real name). “It’s still unbelievable.”
‘As vague as that’
No information was provided in writing at the meetings, though some requested and got this after. “They just talked about this abuse had happened, that this man had sneaked into their rooms and they believed he had carried out some acts. But they didn’t give us dates, nothing, all very vague,” says Colm’s brother. “They sent a letter later, apologising again but they didn’t even say in that what they were apologising for.”
The brother of another victim, given the name “Peter” here, also feels he was given “as little information as possible . . . I had to ask whether the abuse was committed by a staff member or another resident. It was as vague as that.”
The sister of another victim, “Tadhg” (not his real name) sought a copy of the CHO1’s “look back” report after the visit.
In response, Lyons told her in a letter dated January 2019: “We would like more clarity on what specific information you are looking for. We have provided you with the detail of the report as it pertains to ‘Tadhg’ and the recommendations contained in the report during our meeting with you on December 5th 2018 and in a follow-up letter.”
She told The Irish Times: "It is very apparent they felt, 'You've got your apology. You can go now, that's all you're getting'. I feel the HSE had no intentions of ever disclosing any information until they were forced to respond to the claims made by the whistleblower and the follow-up by Thomas Pringle. "
“It’s just too bad”, says Colm’s brother, “because you put your trust in these people to care for your families.”
Among Peter’s brother’s housemates in House 1 would be a man known as ‘Brandon’.
"It is not clear why the decision to move Brandon. was made," says an unpublished investigation into the HSE's management of this man. He could have been kept, along with four other residents remaining in the Seán O'Hare unit. "However the consequences of this decision turned out to be devastating for all the other residents of House 1."
Unknown to their families until three years ago, at least 18 intellectually disabled residents of the Sean O’Hare unit and later the Ard Greíne Court campus were being subjected to sustained sexual abuse by Brandon with the full knowledge of staff and management. This continued for at least 13 years, and from at least 2003.
The brother of Peter is among four next-of-kin of victims targeted by Brandon, who have spoken to The Irish Times in recent weeks. None of the four was told about the assaults until December 2018, a decade after the abuse in some cases.
The whistleblower who had approached local TD Thomas Pringle in October 2016 had exhausted all internal reporting lines, and had contacted gardaí and the Health Information and Quality Authority about the abuse.
Pringle’s reaction, that the allegations were “horrifying” and had to be dealt with, led him to bring the whistleblower’s extensive documentation to the HSE in Donegal and to the then minister for disabilities, Finian McGrath. McGrath sent the files to disability services in the HSE’s national office.
In response, the head of CHO 1, John Hayes, commissioned the "look back" review in 2016 which by November 2018 had established the scale of the abuse.
In its wake, the HSE in Dublin commissioned the National Independent Review Panel (NIRP) to investigate the management of Brandon by HSE disability services in CHO 1. including his care in Ard Greíne up to 2016 and later.
The report, completed in August 2020, remains unpublished. It was only provided to Minister for Disabilities Anne Rabbitte after she told the Dáil in July the HSE was refusing to let her have a copy. She is now pressing for its publication.
Seen by The Irish Times, and titled Independent Review of the Management of Brandon, it catalogues a litany of failures by HSE management to stop the sexual assaults, to report them to the Garda or even to tell families.
“The review team believe that during Brandon’s residency the management at both service and regional level had neither the management skills nor competence to deal with the serious problems Brandon’s behaviour presented,” it says.
It finds that a nurse manager in Ard Greíne made a report about sexual assaults at the centre to “a garda sergeant in the local station” in 2011, but the panel “found no evidence of any follow-up on this report”.
The Garda were again contacted in December 2018 “when a service manager met with the Garda Liaison” to Ard Greíne and briefed the official on the progress of a look back review carried out by the HSE.
The “common” response was to move Brandon around various wards. “Brandon was moved a total of nine times in the 15-year period of this review. While each of these moves provided some respite to the staff and residents from the ward Brandon was vacating, unfortunately they also gave him access to other residents many of whom became the new victims of his abusive behaviour.
“Brandon engaged in a vast number of highly abusive and sexually intrusive behaviours . . . Evidence . . . would suggest that Brandon regularly targeted particular individuals and was able to identify particularly vulnerable residents whom he pursued relentlessly.”
A table of recorded assaults from March 2003 to November 2008, seen by The Irish Times, notes Brandon was found “fondling” a named woman’s breasts; putting his hands between a man’s legs while he sat on toilet; touching another man inside his nappy; masturbating loudly in the sitting room in the presence of other residents; entering residents’ bedrooms naked and touching them in bed; repeatedly groping and molesting the “preferred” individuals andexposing his penis and masturbating for prolonged periods in the presence of other residents.
The recorded response to these assaults was, in almost every case, that Brandon was “removed from” the area or “escorted” to his room. The victim, in case after case, was simply given “reassurance” say the notes.
Throughout this period, nursing staff were demanding that effective action be taken to protect residents. In February 2008, six nurses wrote to management detailing how Brandon had become “overtly sexually disinhibited” and was “sexually assaulting his fellow clients”. They appealed for “this very serious situation” to be brought to a “satisfactory resolution”.
There is “no evidence” this resulted in “any significant changes . . . on the ground”, says NIRP, and 10 months later Brandon moved into House 1 with five vulnerable men. Within days, the abuse restarted: groping and molesting named residents, exposing his penis and masturbating in his housemates’ presence; entering a resident’s bedroom naked; and groping a resident while in his bed.
Throughout 2011, several external experts warned management that Brandon should be moved immediately out of House 1 and the families of victims should be told. A Galway-based psychiatrist whose opinion was sought by the HSE advised in April 2011: “It is totally inappropriate to allow this man to continue to live with . . . vulnerable learning-disabled men . . . The fact that relatives of his known victims have not been informed of the episodes of abuse could be interpreted as collusion or complicity if the situation were ever the subject of an investigation.”
In November 2011, a senior clinical forensic psychologist reported: “It is important to stop his contact with very vulnerable service-users.”
The following month, Brandon was moved to a self-contained flat on the campus, with one-to-one supervision. The abuse reduced dramatically. The respite for the residents of House 1, however, was temporary as Brandon was moved back in September 2013, partly because it was deemed too expensive an arrangement to continue.
Though he was wheelchair-bound and thought unable to assault anymore – the whistleblower who brought the entire case to light asserts – Brandon did continue to assault his peers in the house and on a bus. The NIRP review notes concerns about the serious risk he posed continued to be raised by nurses.
Brandon was discharged from Ard Greíne Court in May 2016 to a nursing home, where he died in 2020.
The families of Brandon’s victims are scattered across the expanse of Co Donegal. None of the four who spoke to The Irish Times knew of the others until recent weeks. None wanted to be identified, with two explaining that elderly siblings knew nothing about the abuse that had been perpetrated on their brothers.
Some express a deep sadness that their brothers had had to go into institutional care at all. Peter went into care as a young child after the death of his mother. "We tried to rear him at home but we couldn't manage," says his brother. He was transferred from a centre in Inis Owen to St Conal's psychiatric hospital when he was 18. "I remember going into to see him in St Conal's. You'd be hanging in the corridor before you'd be let see him . . . They'd be hours getting him ready."
Several times, he says: “You always regret that he’s there at all. You wouldn’t have expected him to be a professor, but he could have kept a few cows and a few sheep. He’d have managed that and been happy.”
The sister of “Albert”, another victim, says there is still a sense of “shame and stigma” about having a family member with an intellectual disability in institutional care. The process of fighting for information about what he has suffered has “helped me recognise Albert as a person within his own right”.
Serious questions are raised in the review about the HSE’s failure to report the abuse and two possible rapes by Brandon in the late 1990s to gardaí. It says it was only when the NIRP team sought assurances from the HSE in 2019 that the gardaí had been formally informed that this was done last year.
On Brandon’s victims still living in Ard Greíne, it does not believe the HSE yet fully understands the impact the abuse is likely to have had on them. “At the time of writing none of these vulnerable people have been provided with an advocacy service. The review panel believes this inaction demonstrates a complete lack of understanding of the need to provide vulnerable people with a voice when they cannot speak up for themselves.”
Perpetrator as victim
It gives some space to Brandon, whom it says could reasonably be described as a victim too. He received no assessments or education relating to his behaviour. “To this end, his behaviour went unabated and earned him the reputation of a sexual predator when in reality the responsibility for both supporting and protecting others fell to the people charged with caring for him.”
An appropriate assessment “may have led to more appropriate planning for him, but was never provided to Brandon”.
The team is most critical of what it calls the “medical model” of care which it says was brought from the hospital setting into Ard Greíne, which treats residents as patients in need of treatment. It led to Brandon’s assaults being viewed as isolated incidents, rather than as a pattern of behaviour.
“The abused individual who was probably traumatised, was simply ‘checked for injuries’ with little or no protective measures taken to safeguard their rights or prevent future attacks . . . The fact that each resident in Ard Greíne does not live in a rights-based environment where they can make real decisions about where they live and whom they live with means residents are completely dependent on staff . . . to protect them.
“This was, in the review team’s opinion, a significant factor in contributing to Brandon’s behaviour being allowed to continue unabated for such a protracted period of time.”
His victims’ families are determined the NIRP report be published as a first step to demonstrating the December 2018 apologies, from Morrison and Lyons, were genuine.
“If they were really heartfelt, and really wanted to make a change, they would want to bring the families with them through the change,” says Tadhg’s sister. “At the moment it feels like that door is closed.”
A file on the case has been sent to the Director of Public Prosecutions.
A spokesman for Anne Rabbitte who was in Donegal on Friday to meet some affected families, said: “The HSE has assured the Minister that there is no ongoing risk to service users and that the national governance and accountability structures to oversee implementation of the recommendations arising from the report are in place.”
In a statement on Friday, the HSE said what happened in the Brandon case “fell far short” of the standards its staff seeks to provide, which are “safe, high-quality health and social care with compassion”.
"We apologise sincerely for that," it said. "An Garda Síochána have asked us to delay publication at this point while their investigations continue."
The NIRP did not provide a comment.
For anyone affected by issues raised in this article, the 24-hour Rape Crisis helpline is 1800 778888