Twenty-seven children and young people in the care of the State or known to child and family services died in 2021.
This is the second-highest recorded since 2010, behind 30 who died in 2020.
Half of those were less than 12 months old and died of natural causes which includes sudden infant death syndrome. Six died by suicide, one less than the previous year.
The report, published on Monday by the National Review Panel, found “shortages or frequent turnover of staff impacted services”.
Dr Helen Buckley, chairperson of the panel, said numbers have been “increasing slowly over the years but that’s probably because the numbers of children referred to Tusla have doubled”, making the service “extremely strained”.
She said the number of those who died by suicide within the care of Tusla is “consistent” with the overall population but remains a “tragedy” as it happened under the State’s care.
The report highlights “inconsistencies” with the Child and Adolescent Mental Health Services (Camhs) service provision, where one branch provided a “consistent and well-coordinated service” with regard to children with suicidal ideation, but another branch said that “suicidal ideation does not constitute a mental illness”.
Dr Buckley said it was “disturbing” and “recurring issue” that Camhs discharges children who have self-harmed or have suicidal ideation. Speaking to RTÉ Radio 1, she said there is a “limitation in health services available for young people with mental health difficulties that don’t conform to a classified diagnosis of mental health problems”.
Of the 27 who died in 2021, four were in care at the time of death, three were in aftercare and 20 were known to social work services.
Since 2010, a quarter of deaths have been by suicide, 40% were natural causes, 8% were due to road traffic accidents, 6% were drug overdoses and 5% were murders. The remainder were other incidents or were unknown to the coroner.