A 15-year-old girl ended up in care after her parents told the HSE they could no longer cope with her behaviour.
The report's authors said she was considered to be both a danger to herself and to others and was in care for nearly three years.
At first this was voluntary but later she was the subject of a court order. In all, the girl was in at least six different placements during that time.
The report noted how she was often missing and living on the streets. On one occasion, she even travelled abroad with a young adult.
While living rough, she associated with older people and presented to hospitals with various self-inflicted injuries. She revealed she had attempted to kill herself on numerous occasions.
She had been under the care of four different case workers except for a period of seven months when none had been allocated.
In the run-up to her death in 2000, many of the arrangements made on her behalf were not appropriate, in one case leading to the breakdown of her placement.
Finally, an application was made to the High Court to allow the social services to detain her in a specialist facility where she was based for about two years, running away on a number of occasions.
While some progress was eventually made, she reverted to socialising with people she had met on the street and to abusing alcohol and drugs.
Finally, she ran away from a work placement and contacted her social worker a number of times over the course of a few weeks.
Her body was discovered two weeks after she broke contact. The review found no information on her file as to the circumstances of her death. It also appeared that there were failures to follow up on allegations she had made of abuse.