The case of the 18-year-old mother of two children who has been found dead while in the care of the Northern Area Health Board in Dublin, demands investigation. Her death came to light this week when the health board gave the news to Mr Justice Peter Kelly in the High Court.
Through her legal representatives she had gone to the High Court last year to seek suitable care and accommodation for herself and her two children.
She was a particularly tragic figure.
Her grandmother - with whom she had been living - died when she was 14 and she was taken into care. According to people who knew her, she had the mentality of a child and was extremely vulnerable to sexual exploitation. What sort of care did she get from the health board?
According to an affidavit to the High Court from her solicitor, Mr Pol O Murchu, she had received 14 different and unsuitable placements, including in bed-and-breakfast accommodation where she had to leave in the morning.
As a result, she wandered aimlessly and was exposed to high levels of risk on the streets. A psychiatrist who assessed her in 2000 described her care as "disastrous".
It is tempting to say that the account of how this health board dealt with one of its most vulnerablecharges beggars belief but, unfortunately, it is all too believable.
This is not the first case of its kind and judging by the views of many people who work with vulnerable children, it will not be the last.
Despite the promises of successive Ministers for Children, we do not have an Ombudsman for Children who could conduct a thorough investigation into how the social services dealt with this girl from the first point of contact. We do, however, have the Irish Social Services Inspectorate and while it deals principally with residential care, it should be asked to conduct an inquiry into this case and to publish a report.
Two years ago, this newspaper revealed that a 16-year-old girl, who had been raped and tortured by her father and who was in the care of the Northern Area Health Board, was effectively homeless. Now we find that a young woman with the mentality of a child has been treated by that health board in essentially the same way and has died. It has to stop.