However, the resident at Joseph’s Hospital in Stranorlar, Co Donegal, was not transferred to a nursing home until 2016.
The report also found staff were bullied and were afraid to speak up about the abuse.
The man went on to perpetrate at least 108 sexual assaults on up to 18 intellectually disabled residents, many of whom were non-verbal.
The man at the centre of the abuse, who is given the name Brandon in the report, an executive summary of which was published by the HSE today, was diagnosed with a mild to moderate intellectual disability and bipolar affective disorder. He passed away in the nursing home in 2020.
The report found that his assaults continued unabated and with the full knowledge of management.
The review, which looked at serious incidents between 2003 and 2016, and was eventually published today by the HSE, found the first recorded incident of sexual assault by Brandon noted on the files is dated January 1997, when he was found to have his hands on the genitals of another resident.
From 2003 onwards, the number of incidents of Brandon’s sexually inappropriate behaviour increased. The first recorded incident in 2003 occurred in January 2003, when Brandon was observed to be touching another resident “inappropriately”. In the period 2003 to 2011, Brandon engaged in a vast number of highly abusive and sexually intrusive behaviours.
Evidence available on file would suggest that Brandon regularly targeted particular individuals and was able to identify particularly vulnerable residents, whom he pursued relentlessly.
The range of inappropriate sexual behaviour by Brandon included:
- Exposing himself and masturbating in the presence of others. This behaviour was very frequent and occurred in the sitting rooms and corridors of his shared accommodation and on regular bus trips.
- Almost nightly prolonged masturbation, which was often accompanied by verbal obscenities being shouted at staff and other residents.
- Sexual touching of other residents inside and outside their clothing.
- Attempting to and succeeding to enter the bedrooms of residents whom he had previously targeted, during the night.
- Targeting particularly vulnerable residents.
- Verbal and physical aggression to other residents and staff.
The review team has identified 18 residents whom it is believed were sexually assaulted by Brandon in the period January 2003 to November 2011.
From November 2011 onwards, there are no further written reports of Brandon assaulting a named individual. However, there are a number of reports on file to suggest that Brandon continued to engage in inappropriate behaviour.
Staff felt powerless and regularly reported incidents up the line in the hope changes would happen.
The report notes bullying of staff and being afraid to speak up and that families were not informed until 2018. There was also a lack of external support from the HSE.
A common strategy was to move Brandon from one ward to another but this just gave him a new group of clients whom he assaulted.
Nursing staff tried repeatedly to stop the abuse and reported it to management.
Brandon was moved to a nursing home in 2016. The HSE said it did not know about the abuse until 2016 as a result of a report by a whistleblower.
Four reports were made to gardaí, the first in 2011, but there was no evidence of follow-up. The gardaí confirmed in 2019 they were carrying out a report on the complaints.
The HSE said it wanted to apologise to residents and their families for the failings in care at a HSE residential and day care service for adults with intellectual disability in the North West and said it fully accepted the findings of the report.
The HSE received the initial report in August 2020, by which time Brandon was no longer residing in the service.
It said that it then acted immediately to seek assurance as to the current safety of the residents within the service.
It said regular safeguarding meetings take place within the service, which has undergone significant reforms, which are ongoing.
“The residents of the service and their families remain our priority,” the HSE said. “All those affected are, and have been, in receipt of a range of multidisciplinary supports. These supports continue to be provided locally, with oversight by senior HSE management at national level.”
However, it added: “To maintain client confidentiality we will not provide details of our engagements with individuals or their families.”
Sinn Féin TD Pádraig MacLochlainn told the Dáil today that the report must be published in full.
The Donegal TD said if lessons are to be learned, and effective safeguards against a repeat of what happened put in place, then all details must be made public.
“We need an acceptable framework to ensure that this never happens again,” Mr MacLochlainn said.
Replying for Government, Tánaiste Leo Varadkar said the HSE advice was that the report cannot be published in full. He said the junior minister for disabilities, Anne Rabbitte, was working with the Attorney General to ensure publication as soon as possible.
Mr Varadkar said the paramount task was to ensure the safety of all people in such care at present. He said for now the advice was that only an executive summary of the report could be published but he hoped this could be changed.