New records uncovered by RTÉ's This Week reveal the HSE was involved in the case of a young woman with intellectual disabilities deemed to be at risk much earlier than it previously admitted.
The woman, known as Mary, was left in a foster home for 18 months after abuse allegations were raised about a carer there.
According to minutes of an internal meeting in September 2014, the teenager's local HSE Disability Service concluded that the intellectually disabled 19-year-old should be removed from the foster care setting at the centre of the sexual abuse allegations.
However, it was not until February 2016 - almost 18 months later - that the woman was finally removed.
In previous statements to This Week in May, the HSE said it took action to make Mary safe in February 2016 within a week of its safeguarding team being notified of a risk of abuse.
However the HSE files, seen by the programme, show that the Executive's Disability Services were aware of the risk to the woman 18 months earlier.
Allegations made against foster parent
The abuse allegations were made against one of the foster parents by a member of their extended family.
There are no allegations of abuse of any foster children in the home.
The allegations were first raised by Tusla with Mary's service provider and the HSE in June and July 2014 respectively.
Two other foster children were removed from the home by Tusla who ceased to use the family as foster carers after deeming the allegations to be credible in June 2014.
On 19 September 2014, a note from an internal meeting in Mary's local HSE Disability Service records that "'Mary' has to be removed".
An entry in the Intellectual Disability Database from three days earlier also records that Mary requires an emergency placement. Despite this conclusion, the young woman remained in the home.
According to HSE files, in late 2014 local Tusla staff in Mary's area advised the HSE that it no longer thought there was a specific risk to the vulnerable young woman.
A further Tusla risk assessment arrived at the same conclusion in 2015 and a local Tusla report in January 2016 also recommended that Mary should remain in the foster home.
That assessment was reversed following the controversy in the media over Grace - a similar case in the southeast involving a young woman left in a foster home after abuse allegations were made.
The relative of the foster family who made the original 2014 abuse allegation also made contact with Tusla expressing concern that Mary still resided in the foster home.
A senior manager in Tusla told the HSE in February 2016 that "with hindsight... this advice (to leave her in the home) was incorrect".
Correspondence from a lawyer advising the HSE in February 2016 in the lead-up to Mary's removal makes reference to the late 2014 period when the young woman was left in the foster home, despite a HSE belief that she should be removed: "As I understand it ... the view 18 months ago, at the time of the assessment of the allegations of sexual abuse, was to the effect that there was no mechanism by which the HSE could remove her from the placement.
"I would like to have precise details of the decision making process at that stage".
Confusion over responsibility for Mary
Other documents show there was considerable confusion and disagreement within the State agencies and a local service provider as to who was responsible for Mary's care.
Following the abuse allegations, both Tusla and the HSE called on the local provider of the young woman's day service to carry out a risk assessment on the safety of her placement.
The service provider informed both the Tusla and the HSE it had no legal mandate to do so.
In a letter to Tusla in July 2014, the service provider wrote: "No arrangements have been made for (the service provider) to be legally responsible for Mary's future ... We are concerned that Mary is safe in her home ... responsibility for Mary's future lies with the HSE".
HSE records also show that it received a letter from the service provider on 8 September 2014 advising it that "(the service provider) have (sic) no mandate to risk assess".
An email from a senior local HSE Manager in 2014 also raised concerns about HSE staff putting the onus on the service provider to carry out a risk assessment: "I don't think it is enough to put this back on (the service provider)".
In response, the HSE official who had asked the service provider to do the risk assessment wrote: "I was putting it back on (the service provider) while we were working on a solution".
Minutes of a care planning meeting in March 2013 outline the division of responsibility for the vulnerable teenager's care between the HSE Child and Family Service (later Tusla), HSE Adult Disability Services and the local service provider after she turned 18 years of age.
At this meeting, Tusla, which was then still part of the HSE, stated that it could not provide adequate supports to Mary due to her complex needs.
The minutes note that: "'Mary' will not receive support from Aftercare Services of Child and Family Services (later Tusla). Disability (HSE Disability Services) is best placed to offer this support due to her complex needs".
A report on the case prepared in May 2016, following coverage of the case on This Week, notes that there are "clearly questions in relation to the effectiveness of the collaboration between Tusla and the HSE".
Removal from home 'traumatic' for Mary
When Mary was ultimately removed from the foster home in February 2016, the effects of the overnight change of care setting, as opposed to a more gradual transition, left her "heartbroken" according to minutes of one meeting and were described as "particularly traumatic" in another.
A letter to the HSE dated 3 March 2016 from Mary's service provider also complained about the manner of her removal, describing it as "thoughtless and cruel".
The letter also states that a more gradual transition should have been considered: "On the day she was abruptly removed, no evidence or new information regarding Mary's placement was presented ... the same knowledge has been known to a number of professionals for over two years, a few more weeks to make a person centred transition should have been allowed."
A gradual transition for Mary was discussed at several HSE meetings as a sudden move would be "detrimental to her well being".
A number of documents seen by This Week also record that a "directive" was issued by the HSE's National Director of Social Care Pat Healy not to allow the young woman return to the foster home after her day service on 15 February 2016, a move that Mary was not expecting.
In statement to This Week as to why the National Director had issued this directive, the HSE said the decision to remove Mary from the foster care setting in February was made by local HSE staff.
Documents also note that there is no evidence that Mary was a victim of sexual abuse.
The HSE, Tusla and the local service provider all told This Week that they would not comment until an ongoing inter agency review of the case was completed.