Did an inadequate health board response contribute to the death of ayoung mother? Padraig O'Morain believes an investigation is neededto establish the facts.
Dublin's ramshackle child protection services claimed another victim in the past few days: the 18-year-old girl with the mind of a child who had been in the care of the Northern Area Health Board for the previous four years.
Two years ago, a psychiatrist described the care she had been receiving as "disastrous".
Last year her solicitor, Mr Pól Ó Murchú, told the High Court how she had been placed in bed and breakfast accommodation which she had to leave every morning to wander the streets "aimlessly".
This week, after news of her death from an apparent drug overdose was given to the High Court, people who work with disturbed children used words such as "traumatised", "disgusted", "angry" and "saddened" to describe their reactions.
On one level, it is unfair to blame her death on the child protection services. If, as it appears, she died of a drug overdose, then the primary responsibility lies with whoever supplied her with those drugs.
She was very vulnerable to sexual exploitation from the age of 14 and responsibility must also lie with those who took full advantage of that.
But the poverty of the Northern Area Health Board's response to her need must surely be thrown into the balance as well.
Last year the High Court heard that while she was in voluntary care with the board, she had 14 different and unsuitable placements, including in bed-and-breakfast accommodation.
If parents treated a needy child in this way they would be regarded as neglecting and emotionally abusing the child. That a health board, which is there to step in when the family fails, acted in this way is incomprehensible.
Yet, it does not come as a surprise.
For how many years have social workers and campaigners been complaining that they cannot find services as basic as safe accommodation for vulnerable children? For how many years have we been hearing of cases of suspected abuse and neglect not being followed up in Dublin because of a shortage of social workers.
The most recent description of how bad things are came in an editorial in The Irish Social Worker published a week or so before the death of this unfortunate girl. "Literally thousands of cases of suspected child abuse are unlocated," wrote editor Mr Kieran McGrath.
Many children in care have no allocated social worker and a consequence of this lack of backup is that "many of these placements break down and the children are then described as out-of-control and their cases end up in front of Judge Peter Kelly".
Not surprisingly, "social workers are voting with their feet and leaving health board social work at an alarming rate". Some social work teams have less than half their complement of social workers.
This being so, what chance did that tragic girl have of getting the help she needed, help which would have included a secure setting in a specialised therapeutic environment?
And where does this leave other girls like her? Sources are adamant that there are others like her in the system, very young girls who need containment and therapy and who are not getting it.
These sources also believe that health board managers at a senior level could have done more to find a secure placement for this girl. Certainly there has been a terrible failure here.
This girl was placed in care after her grandmother, with whom she had been living, died. While in the care of the health board, she became pregnant twice. Her two children are in care. This in itself is so bad it should ring alarm bells at the health board. The sound of alarm bells ringing is, however, noticeably absent.
There is another aspect to this which predates what we know of health board involvement.
This girl, we can assume, went to school. If she had a psychological disability, there is every likelihood that her teachers attempted to get help for her. But the schools' psychological service was and is so underdeveloped that there is also every likelihood they were unable to get her that help.
If so, this girl is yet another casualty of a lackadaisical attitude to mental health services which has cost many children and their families dear - Brendan O'Donnell, who killed three people in the 1990s was, perhaps, the most shocking example of the price we pay for inadequate mental health services for children and teenagers.
But how are we ever to know who did what and who failed to do what for this girl?
An internal health board investigation would impress nobody. The Irish Social Services Inspectorate deals with residential care. The Children's Ombudsman has failed to materialise.
An Ombudsman for Children could review the steps of this child's contact with the social services from an early age and could publish a report on it.
The purpose of such a report would not be vindictiveness but to expose flaws and shortcomings so that they can be fixed.
The difficulty is that although the establishment of an office of Ombudsman for Children has been official policy since the then Minister for Children, Mr Austin Currie, announced it during the Rainbow Coalition, it just hasn't happened.
But despite the absence of a political outcry - how used we have become to this sort of thing! - this case needs investigating.
Minister for Children Ms Mary Hanafin should ask the Irish Social Services Inspectorate to depart from its normal remit, to investigate this case and to publish a report.
We failed her in so many ways - let us at least find out how, before the next child dies.
• Padraig O'Morain is Health and Children Correspondent of The Irish Times