"Missed opportunities" are cited in the care of a teenage asylum seeker whose pregnancy was terminated by Caesarean section this summer.
The baby remains in the care of the State.
A draft Health Service Executive report into the care of the woman, known as Ms Y, says agencies were constrained by existing legislation, as well as a lack of coordination.
The report, seen by RTÉ's Prime Time, said Ms Y had not been identified as being at risk of suicide until 22 July when she was referred to mental health services.
The pregnancy was terminated pursuant to the Protection of Life During Pregnancy Act on 6 August.
Ms Y alleges she was raped before arriving in the country in April.
The report finds that Ms Y did exhibit signs of "extreme emotional distress" and that there was a consistent view that "the most appropriate referral was for crises pregnancy counselling".
The report says "efforts were made to assist Ms Y to secure the necessary documents to travel abroad for a termination of pregnancy as she wished but this process was not completed".
Ms Y was also seen by a doctor specialising in the care of victims of torture, who recorded that Ms Y had a "strong death wish" but was not actively suicidal.
The report, which does not include an interview with Ms Y, is in draft form and may contain inaccuracies, according to the HSE.
The HSE said in a statement that the report has not yet been completed.
"As the work of the review team is ongoing at this time, any draft documents in circulation should be treated as such and cannot be considered to present a full and final view of the work of the team compiling the report," it added.
A HSE spokeswoman said the team is seeking to meet Ms Y and is in discussions with her legal representatives regarding the necessary arrangements to support her in providing her input into the report.
