WHEN 'young person in aftercare 23' was found dead in his hostel room, the first person notified was his social worker.
The 20-year-old, first taken into care with his siblings when he was nine months old, had named his social worker as his next of kin.
That social worker had spent the past five years of his life fighting to keep him out of prison and off the alcohol and drugs he so heavily abused.
Once he turned 18, she visited him every day to provide him with emotional and practical support. He died, despite her best efforts to save him.
The unnamed social worker was one of a small number of HSE staff singled out for praise by the Report of the Independent Child Death Review Group (ICDRG).
The report, which chronicles the lives and deaths of almost 200 children in care during Ireland's Celtic Tiger years, has exposed major failings in the State's handling of vulnerable children.
It has also shone a light on the challenges of dealing with disturbed young people -- and reignited the fraught debate of how and when the State should intervene to protect troubled children.
Children such as Devlin Kavanagh.
He was aged just 14 when, six years ago, he took his own life following a brief and turbulent spell in the care of the State.
The complex story of Devlin's tragic demise may never fully come to light. As a minor, subject to childcare orders, much of the detail leading up to his death cannot be published for legal reasons.
Devlin was received into care after his mother, Orla Kavanagh Doyle, and stepfather, Mark Doyle, asked the authorities for help. They turned to the State in 2005 when Devlin, aged 13, began displaying symptoms of depression and self-harming.
His family had just returned home from two years in the US where, according to Mark and Orla there had been "absolutely no problems". The problems began, according to Mark, when Devlin moved from primary to secondary school.
Devlin, who had been diagnosed with learning difficulties, had befriended older, undesirable friends.
He had been enrolled at Knockbeg College, in Co Carlow, but he got himself expelled deliberately, according to Mark.
"To my mind, Devlin's exit from the educational system was the beginning of the end for Devlin," Mark told the Irish Independent.
On July 7, 2005, Orla and Mark contacted the HSE Child and Adolescent Mental Health Services (CAMHS) and the HSE's Social Work Department for help.
Devlin was placed into voluntary care and, as his life spiralled out of control, he was placed for three months into a secure residential centre. But after his release from the secure unit, efforts to reintegrate him through a 'step down' facility failed and he absconded.
There is no doubt Devlin's descent was fuelled by his own conduct.
Two weeks before his death, the teenager made it clear to his mother that if he was returned to the secure unit, he would end his life.
She passed this information on to his social workers and a report by the Ombudsman for Children found there was a failure by authorities to take the family's concerns seriously.
It also found that he was not permitted to stay in secure care long enough to address his problems
Four days before his died, Orla Kavanagh sought a Care Order from the High Court to allow Devlin to be taken into the care of the State.
Orla and Mark are plagued by thoughts that Devlin's life could have been saved had they secured private psychiatric services.
This is the burden of what-ifs placed on dozens of families and others who did their best to prevent the deaths of children in care.
comment: David Quinn & Alison O'Connor, Page 28