The death by suicide of a teenage girl has thrown gaps in mental health services for young people into sharp relief.
Dr Helen Buckley, chair of the National Review Panel that reviewed the girl's death, said it was not the first time that the panel had identified this service gap.
The panel's report highlights that young people who are suicidal, with addiction and behavioural issues are not considered eligible for mental health services.
Dr Buckley said:
This service gap has been identified many times by the NRP and needs urgent attention from the HSE and Department of Health
There are no residential addiction services for girls and NRP's report also recommends that this matter is also brought to the attention of the HSE.
The girl, known as Niamh (not her real name), died by suicide when she was 15 years old.
She came into contact with Tusla, the Child and Family Agency, a year earlier because her behaviour was causing concern.
She had an older boyfriend and was found under the influence of drugs and alcohol. She also had some health problems and a history of self-harm.
Her parents had parted when she was young and both went on to develop new relationships.
Niamh had contact with her father. Her mother was very concerned about her welfare and open to support from services.
The child agreed to go into foster care for a short time while a care plan that included attending an addiction service was agreed.
However, the counsellor at the addiction service believed she needed residential addiction treatment but no such services are available for girls of her age.
Niamh was twice referred to hospital for emergency psychiatric assessment and was eventually placed on a waiting list for Child and Adolescent Mental Health Services but had not received an appointment when she died by suicide three months later.
The NRP also reviewed the deaths of two children from sudden infant death syndrome who were known to social work services at the time of their death.
One of the babies called Oscar (not his real name,) died two weeks after he was born with traces of cannabis and cocaine in his system. His mother was a vulnerable young woman who struggled with addiction and homelessness.
The panel found his death was not related to a service deficit.
Another baby, known as Kim, who had been born three months prematurely, died when she was 10 months old. Her parents were members of the travelling community and her mother had an intellectual disability.
There was a strong focus on Kim's needs by professionals and agencies. Many professionals had advocated on the family's behalf to the housing department in an attempt to secure appropriate accommodation but were unsuccessful.