Another serious safeguarding incident is "conceivable" if the HSE does not address governance and oversight issues at residential disability centres in Co Donegal, according to the healthcare watchdog.
The Health Information and Quality Authority (Hiqa) issued the warning after it carried out inspections at 18 centres in the northwest in January.
It identified a number of shortcomings following a “very serious” safeguarding incident in a HSE disability centre last year.
A report completed by the National Independent Review Panel (NIRP) in August 2020, found that a former resident of the centre, given the pseudonym Brandon, perpetrated at least 108 sexual assaults on upwards of 18 intellectually disabled adults, most of them non-verbal, between 2003 and 2016.
In October 2021 Hiqa was notified of a separate safeguarding incident in a HSE-run centre in Co Donegal, which it described as “very serious”. The incident had occurred in July 2021 but Hiqa had not been notified until October.
The regulator said after these safeguarding issues it escalated concerns to senior HSE staff and began its own regulatory review.
Hiqa’s review, published on Friday, found there was a “heavy reliance” on individual people in charge of HSE disability centres in Co Donegal “without sufficient accountability”.
The watchdog said this “significantly increased the risk of safeguarding or other issues arising and not being identified and responded to in a timely manner”.
Hiqa carried out inspections in 18 of the 30 HSE residential disability centres in Co Donegal in January 2022, with several other facilities inspected in previous months.
The review found there had been previous times when the HSE took action to improve safety standards in certain centres, “but then failed to ensure that those improvements were sustained”.
The regulator said “of particular concern” was the fact the HSE’s own “surveillance and oversight” of its centres had failed to identify issues.
The HSE was warned a failure to make improvements would result in the centres being shut by the regulator.
Overall, the Hiqa inspections found that the HSE needed to improve the effectiveness of its oversight of residential centres.
“Should there be failure to address these poor governance and oversight arrangements, it remains conceivable that another safeguarding incident may occur similar to that which was identified in November 2021,” the review said.