One would have to have a heart of stone not to be deeply moved by the stories of the almost 200 children who died in the care of the HSE over the past decade, which were published yesterday.
The Report of Independent Child Death Review Group does not paint a flattering picture of the care provided by the State to deeply troubled children and recommends a root-and-branch reform of the child protection system.
It concludes that in the majority of the cases it examined, the children concerned did not receive adequate protection.
It goes on to catalogue a series of failures including the lack of proper co-ordination between the different state agencies involved in dealing with children in care, poor record keeping and a lack of proper risk assessment.
Perhaps the report's most shocking conclusion is that, while many of the 196 deaths it examined were from natural causes, 112 of the deaths were not.
The report stated that many of those deaths which were not from natural causes were preventable.
These conclusions are deeply shocking. Children's Minister Frances Fitzgerald spoke for us all when she expressed her deepest sympathies on behalf of the State and Government to the families of the dead children.
While the review group is surely correct to highlight the failings of the system for dealing with children taken into care, it is important to remember that many of these children were already deeply troubled before the HSE assumed responsibility for their welfare.
However, no such excuses can be made in the case of the 32 children who died in the HSE's "aftercare" service.
Given what we now know, 27 of these children -- more than five-sixths -- died from non-natural causes. Serious questions need to be asked. These were not children about whom the HSE knew nothing. They had already been through the system.
Yet 14 of these children died from drug-related causes and a further seven from suicide. Was the HSE's so-called "aftercare" system for these troubled and vulnerable children worthy of the name? On the basis of the report's findings it is hard to have any confidence that it was.
While individual social workers work extremely hard on behalf of children in the HSE's care, the picture that emerges from the report is of a disjointed, dysfunctional system in which it is all too easy for some children to slip through the cracks -- with sometimes tragic consequences.
Now that the report has been published, the weaknesses it has identified must be rectified as soon as possible. Even one avoidable death of a child in care is one too many.