You’d think a report that took eight years to write could perhaps squeeze in time for an executive summary.

I’m going to take an educated guess that few, if any, of the readers of this column will have sat down to read all 2,000-ish pages of the Fennelly Commission report last week. That’s fair enough: I won’t pretend to have read the whole thing either. You’d think a report that took eight years to write could perhaps squeeze in time for an executive summary.

As an aside, the political establishment – that is to say, the politicians who initially championed Grace’s case, and who sanctioned the public inquiry into her treatment – should spell out exactly what it is they’re disappointed about. Is it that the Commission took years and years to report, and basically stopped short of being able to point the finger? Is it that the findings are generally so wishy-washy at all? Or is it that the claims of sexual abuse against Grace, advanced by those politicians as the catalyst for the inquiry in the first place, couldn’t be backed up?

But a broader point highlighted by Fennelly – and one worth reflecting on – the general systems used by the HSE to supervise the placements and care of those with intellectual disabilities, or who are incapable of minding themselves. They go beyond the care of Grace and ought to be a serious concern.

For about two years between the ages of 28 and 30, and after Grace’s birth mother inquired about her welfare, the management of Grace’s case was the subject of a ‘Vulnerable Adult Committee’. In principle this was the forum where major decisions about her future were to be made, with input from social workers and others in disability services.

Except from the very outset, the mission seemed doomed to failure. A ‘draft’ policy for how VACs were to operate was never actually adopted as being official, so there were poor terms of reference from the very off. There was no fixed formula for deciding who would be on, or off, the VAC: its membership seemed fluid over time; eight named people are listed as having attended.

Because of that fluid membership, there didn’t seem to be an obvious chain of command. Though it had the same chair for its first few months, there wasn’t a system for taking minutes, so there wasn’t always a universally agreed record of what had been discussed. Even when there was agreement on outcomes, there was little evidence of coordinated follow-up to determine if changes had been made. Most chillingly, the Commission doesn’t make any mention of whether this format of care has been put right - or whether structural defects like those of the VAC remain in place to this day. Without being told otherwise, one must assume they’re still in place today.

This should ring alarm bells for anyone with any interest in the welfare of vulnerable citizens. That’s not just the treatment of some isolated case: it’s a systematic flaw in the care of any citizen.

Every family in Ireland is, say, one car accident from that becoming their circumstances. And it’s not nearly good enough.