Tracey Fay didn't slip though the system, says one social worker who knew her."The problem was what happened to her once that system got hold of her. The system is a mess."
This social worker first came into contact with Tracey when she was 14, and describes Tracey experiencing "corporate neglect, which is to my mind abuse".
The words may seem harsh and they came from an angry worker reacting to what she saw as the "preventable" death of a child she had known well for two years. But there are many who agree with her.
"I've been in social work for over 10 years and the last five have been the worst ever," says this social worker. "What has been happening to hundreds of kids drifting through our services has been a national disgrace."
Mr Kieran McGrath, editor of the Irish Social Worker, agrees that the "child protection services are worse than a few years ago".
Money is not the problem, he goes on.
"In the past it was. Now we can get the money for practically anything. But there's nothing to spend it on."
He speaks of a lack of facilities in which to house troubled, at risk children and a lack of back up services social workers should be able to call on - such as child counselling. The result is that child-care workers are "leaving in droves".
Despite extensive recruitment drives by each of the the three health boards in the Eastern region, there are numerous areas where there is an inadequate number of social workers.
In one, says Mr McGrath, there are less than half the full complement of social/childcare workers.
A second strand to the problem, according to a spokeswoman for the Irish Association of Social Workers, is that "a huge sense that management is unmanageable".
"There are more and more people in management, there's more paperwork, layers of bureaucracy and edicts coming down from on high, when the people at the chalk face know that what they need is plain support, people they can discuss complex issues with. Local teams," she says, "need more autonomy and less central planning."
She says that when one social worker feels a child needs something they have to fill in forms, "go though layers of red tape". It means delays and even that "things don't get done. It's a huge mess".
Numerous social workers with whom The Irish Times has spoken, repeat complaints published three years ago in a report, by Scottish social work consultant, Mr David McKendrick. Throughout he spoke of a lack of clarity as to who was responsible for various areas, or could make decisions, excessive workloads, "poor" working conditions and a lack of supervision and support for child-care workers.
"No real action, as far as those of us at the coal-face are concerned, has been taken to address those issues," says the AIASW spokeswoman.
The three Eastern Regional Area Health Boards argue that they have embarked on extensive recruitment drives but "have great difficulty in recruiting a range of health care staff required".
Mr McGrath says there should be an exit-survey which asks child-care workers why they are leaving the particular area of social work.
"There's no point recruiting all these people if they are going to turn around and leave after one or two years."
The IASW speaks of the fact that child-care workers do not feel free to criticise the system in which they work, whether that be in response to an angry judge in the Children's Court or a public blaming them for failures.
"You're left feeling totally vulnerable, totally to blame if things go wrong and thinking, 'This is a mug's game'.
"We're only a cog in a wheel. What's needed is a total overhaul of the system," said the IASW spokeswoman.
"Where those at the coal-face are actually listened to an allowed to do our jobs as professionals."