An inquest has heard how a teenager in State care was found dead in a Cork squat clutching rosary beads.
Seventeen-year-old Christopher O'Driscoll died from severe pneumonia, but today the Coroner's Court in Cork was told that drugs played a significant contributory role in his death.
The HSE has confirmed that the case has been notified to the independent review group set up to examine the deaths of children in care.
In a statement, it said the unexpected death of a child under any circumstances is a tragedy, but particularly so when efforts to care for vulnerable children break down.
Today's inquest heard O'Driscoll had a complex history of contact with social services from the age of 10, and started taking drugs at 12. His life had become chaotic in the months before his death, the inquest was told.
In early May 2009, a social worker had to book him into Jurys Inn in Cork because there was nowhere else for him to go. However he was thrown out of the hotel, and despite going missing, his disappearance was not reported to gardaí.
On May 6, 2009, a woman spotted his lifeless body in a squat in Strowan Villas and called the emergency services. But when they arrived, they missed his body, which was not officially found by gardaí until two days later.
His death was from pneumonia, but drugs like heroin, and benzodiazapene were a contributing factor.
Christopher's mother Miriam Hayes said she believed more could have been done to help her son, and that she feels he "fell through the cracks" in the system.