The killing of 17-year-old Daniel McAnaspie in 2010 was one of several tragic deaths of young people which would prove to be the catalyst for the setting up of the standalone child and family agency Tusla.
His story was one of the most damning in a 2012 report of the Independent Child Death Review Group, which looked at the deaths of 196 children and young adults in care, aftercare, or known to child protection services over a 10-year period.
Daniel was known to the HSE from an early age and the report laid out in detail how he was repeatedly failed during his all too short life.
The report documented no fewer than 17 examples of poor care.
The failings were so serious authors Geoffrey Shannon and Norah Gibbons recommended a full review of his case.
Daniel's parents were known to the health service prior to his birth and he was just four when his father died of a drug overdose.
Despite concerns about alcohol abuse by his mother and the effect this had on her ability to care for her children, the HSE closed the case file when Daniel was just six. No explanation was given.
The case was reopened three years later after two school principals and a social worker raised concerns about the family. When Daniel was 10 it was decided a full care order should be applied for, but more than two years elapsed before this was made. By this stage he was almost 13 and in need of speech and language therapy and anger management sessions.
He had severe dyslexia, but this was not diagnosed until he was 15, the same year his mother died.
The report detailed how he had 21 placements between the ages of 10 and 17. Some 16 of these were in the last year of his life.
When he was 16, the HSE social work department tried to get him admitted to a special care facility, but this was refused because he did not meet the criteria. A guardian ad litem recommended he be placed abroad, but there was a failure to act on this recommendation.
He ended up being placed with a residential service which was not in fact registered with the HSE.
After four months he was moved again after the placement was terminated due to alleged drug taking and alleged involvement in criminal activity. Fifteen days later he went missing from a house where he was living. His body was not found for almost three months.
The case was a classic example of a child falling through the cracks of a chaotic system. Although he was offered many services these often didn't match his needs. Sometimes he had a number of social workers and other times none. Management supervision of his case did not appear to be evident.