The Child and Family Agency has apologised for what it says were unacceptable shortcomings in the care of a teenager who spent much of his life in state care before dying of a drug overdose.
Danny Talbot - who was called Luke in this report - died of a drug overdose at 19, after being in foster care from the age of 10 and later being placed in a residential unit and an emergency homeless hostel.
A report from the National Review Panel found there were serious weaknesses in management and accountability within the HSE around the case.
It finds there was an inadequate response to evidence he had been abused and neglected as a child, his needs were never properly assessed throughout his life and his placements were not matched to his needs.
The Director of Policy and Strategy at the Child and Family Agency Tusla, Paul Harrison, said there were considerable shortcomings in supporting and protecting this vulnerable young person.
"The intervention provided was insufficient and it was poorly coordinated, " he said.
"We acknowledge this and we apologise for it. There were shortcomings that were not acceptable, and despite the fact that it's a case of some age now, we do accept and apologise for that."
"Since these tragic deaths, there has been a radical change in the way we respond to vulnerable young people.
"Tusla is committed to the review of previous failings and to ensuring that the legacy of those failings is a renewed determination not to fail future generations, future individuals."
Among the planned reforms are an expansion of out-of-hours services, a new assessment framework, and a revised protocol between Tusla and the HSE to discuss "complex cases" every six weeks.