"She was a little princess when she was nine years old."
This is how Kim O'Donovan was described by a woman who had been close to her and spoke to The Irish Times after her death last year.
How did the little princess become the young teenager who died after taking heroin in a bed and breakfast establishment?
So far as we know, Kim was adopted from an institution at 18 months by Ronnie and Maura O'Donovan and grew up in a normal environment.
At about the age of 11 she started to become difficult to manage, wanting to behave in ways that were beyond her years.
Her family sought help and she was ultimately taken into care by the Eastern Health Board. This involved foster care and other temporary accommodation before she was sent to Newtown House in Co Wicklow.
By now, the system had failed. She herself made choices - such as running away - which were difficult to cope with outside a specialised setting.
But that specialised setting did not exist. Such services had been called for over many years by groups lobbying for children but policy-makers had turned a deaf ear to them.
Now, with health boards under pressure from Mr Justice Kelly to provide services for the children appearing before him, the East Coast Area Health Board turned Newtown House into a secure residential unit. As the Irish Social Services Inspectorate later found, the staff were largely untrained, with little back-up from the psychological service, and the house was unsuitable.
Kim made some destructive choices when she was there - for instance she embedded a pen in a staff member's face and he was out of work for two months - but the staff persisted.
Finally, it seemed as though she could safely go to a less secure setting and she was sent on work experience.
From there, she made the final, fatal choice to run away.
But the truly fatal choices had been made again and again many years earlier - by those who chose to turn a deaf ear to the experts, activists and workers who had sought a comprehensive specialised service for very troubled children.
And we haven't got it yet.