Our old friend “systems failure” pops up all over the report. There is an acknowledgement that Tusla is not being run as set out by its mandate. Simple matters such as adequate record keeping are not being addressed. Children who are not at immediate risk are not being properly handled. And nobody carries the can.

The culture of “looking for a head” is overblown in the current body politic, often providing little beyond an outlet for frustration and anger. The flip side of that, however, is that sometimes it is necessary to at least highlight who is not doing their job properly and whether things can be improved if such a person continues in their position.

The publication of the Investigation into the Management of Allegations of Child Sexual Abuse against Adults of Concern will do little for anybody wishing to see a culture of accountability.

The investigation was launched in the wake of the shocking revelations in February last year that a false allegation of sexual abuse against Sergeant Maurice McCabe was generated in Tusla in 2013. Minister for Children Katherine Zappone ordered the inquiry.

One of the terms of reference directed the inquiry to avoid, as much as possible, any overlap with the Disclosures Tribunal, which also examined the Tusla/McCabe issue. The evidence at the tribunal into what befell the whistleblowing sergeant fits neatly into the findings of this report.

The report does acknowledge that a lot of people in the agency are doing good work. It also makes plain the issue of recruitment and training for staff.

However, it points to a whole list of shortcomings that do put children at risk.

Managerial oversight is one of the major shortcomings identified.

There is a failure to ensure that practice on the ground is driven by policy. Poor performance at all levels is, in some instances, neither being detected or corrected. And record-keeping is classified as poor.

Three key defective points were identified. In the section ‘Screening and Preliminary Enquiries’, it found “inconsistencies in practice” which meant “that not all children at potential risk were being assessed and where necessary, protected by Tusla in a timely and effective manner”.

In ‘Safety Planning’, Hiqa found “inconsistencies in safety-planning practice by Tusla for children meant that while some children were adequately safeguarded, others at potential risk were not”.

And the management of retrospective cases “did not include a standardised approach to direct and guide staff in case management, leading to variation in practice and delays”.

In relation to the McCabe case, no specific personnel were identified as bearing any responsibility. However, it is possible to correlate the evidence heard at the Disclosures Tribunal with the systems failures Hiqa found.

We know from the tribunal that the following litany of errors occurred:

- Counsellor Laura Brophy was told that an historic allegation against Sgt McCabe was not on file in Tusla. This was erroneous. It was on file, but when told it wasn’t, Ms Brophy was compelled to submit a new referral;

- Ms Brophy made a typing error in the referral, mixing Sgt McCabe’s innocuous, and effectively closed case with a serious case of child rape. However, within Tusla, she had over the phone made the correct referral but the discrepancy was not noted;

- In April 2014, a social worker extracted the file to make a notification to the gardaí. She had both the correct phone notes and the false child rape referral. The discrepancy was not spotted;

The notification was not discussed at the next weekly conference. If it had been, the major error would have been detected;

- The mistake was detected by Miss D when informed by her garda father in May 2014. Despite this, a new referral with the correct allegation was sent to the gardaí even though this had been comprehensively dismissed following a Garda investigation eight years previously;

- In May 2015, the file was accessed by another social worker who, using the erroneous allegation which had been corrected 12 months previously, drafted a letter to Sgt McCabe asking him to attend for interview on the basis he could be a risk to children.

- This draft was given the OK by the head of Tusla in the North East, Gerry Lowry. He told the Disclosures Tribunal that he did not open the email attachment on which the draft was written. This was despite the discovery a year earlier of a grievous error in this case;

- The letter was sent to Sgt McCabe. This alerted him to what was going on, which was ultimately exposed in February 2017. At no point was Sgt McCabe informed of what had occurred within the agency.

All of these types of shortcomings were identified in the Hiqa report. In the case of Sgt McCabe, the result had a devastating effect on his and his family’s life.

In the case of children who are at risk, the shortcomings can lead to a situation where the agency simply does not do its statutory duty to protect them.