AN INQUIRY into the case of a teenage girl who died while in the care of the State has highlighted a series of failures and missed opportunities by the child protection system to provide her with proper care.
Tracey Fay, an 18-year-old mother of two from Coolock, in Dublin, died of a drugs overdose in January 2002, after spending four years in the care of her local health authority.
An unpublished report commissioned by the Eastern Regional Health Authority - now the Health Service Executive (HSE) - says social services did not provide her with appropriate care and support, placing her at risk of abuse and exploitation.
Instead of giving her stable accommodation, it provided a "chaotic" response including 20 different BBs, hospital beds, a bench in an AE ward, and two different dedicated services over a four-year period.
She spent much of her time wandering the streets, the report notes, as she was not allowed access to BB or emergency care accommodation during the day.
Despite describing her as "nervous and unstreetwise" at the age of 14, social workers were seriously concerned for her welfare less than a year later. Social care files contain letters showing gardaí and health professionals were increasingly worried about her drifting into crime, prostitution and, later, drugs.
There was also a series of "missed opportunities" to provide her with therapeutic services.
In total, there were six documented cases of recommendations for her to be assessed by health professionals which did not occur within a reasonable time frame.
A two-year delay in getting a full psychological assessment "undoubtedly led to delays in ensuring her needs, abilities and competencies" could be established.
The 100-page report by independent childcare expert Michael Bruton, seen by The Irish Times, contains some 50 recommendations to reform child protection services.
It suggests sweeping changes to the child protection system, such as banning the use of BBs for children in care and automatic investigations into the deaths of children in care.
The HSE has not commented on the report. It is expected to publish the findings after publicly announcing its decision to independently review the case six years ago.
Damien Fay, Treacy's uncle, said yesterday he hoped the report would highlight what went wrong with the child protection system.
"You would expect the social services would be in a position to care for a vulnerable girl like Treacy, but the system failed her," he said.
Social workers say the flaws highlighted in the report are still placing other vulnerable children at risk.
Unpublished figures show that hundreds of cases of suspected abuse or neglect are not being followed up due to staff shortages or heavy caseloads. In some community care areas, there have been delays of up to three years in dealing with abuse referrals.