An independent review of the case of a 15-year-old girl who took her own life while in foster care has questioned whether the social services fully understood the significance of separating her from her younger sibling very early in their lives.
The report by the National Review Panel also criticises failures to allocate a social worker to the older child, in one instance for two years.
Although commissioned by the child and family agency, Tusla, which is responsible for children in State care, the NRP has been functionally independent of it since it began its work in 2010.
The executive summary of the review of the teenage girl's suicide is one of eight such documents published by the NRP on deaths of children in care, all but one of which took place in the past three years.
Calling the girl "Clare" to protect her identity, the review says she had been in care since the age of two, fostered by relatives for the first 14 years and later by a number of carers for varying durations.
Clare was described as warm, attractive and outgoing, intelligent and socially active but also emotionally very fragile and deeply affected by the deaths of her mother and one of the relatives who had cared for her for many years.
She was first placed in voluntary care with relatives while her younger sibling was placed with a mainstream foster family. The children's mother died from an overdose when Clare was four.
The report says that initially, the question of placing both children together was considered and while Clare's relatives were unsure of their capacity to take care of two children, they later asked to foster Clare's sibling as well.
It notes that Clare's mother had opposed this before her death, asking instead for the two children to be placed together elsewhere. Ultimately the Social Work Department decided to leave the children where they had become settled.
It states that Clare was considered to be well cared for and happy living with her relatives until she was 12-years-old and had had regular contact with her sibling, which she valued.
Although curious about her father, she never met him while in care.
For a number of years difficulties between her relative carers and her sibling's foster carers meant that the social work department had to supervise contact visits.
She began to self-harm and expressed suicidal ideation following the death of her male relative carer when she was 12. She had been very close to him and she refused to conform with the boundaries her remaining carer set for her.
She attended the Child and Adolescent Mental Health Service but her school expressed concerns about her and ultimately her relative carer could not cope with the stress of the self-harm and she was moved to another placement.
She soon moved into a foster placement where she stayed for 13 months.
Although her self-harming reduced considerably, strains emerged because she wanted to spend more and more time with her boyfriend who was two and a half years older and on whom she had become very emotionally dependent.
Her foster placement ended after she mitched from school, did not return home for two days and instead stayed, concealed, in her boyfriend's house.
While the Social Work Department then pursued a residential placement, Clare had short-term placements.
The Department and her former carers were concerned about the intensity of her relationship with her boyfriend and her inability to deal with the vicissitudes of a normal teenage romance which was off and on at different times.
She formed a very good relationship with her second short-term carer, and began a process of transition to the residential unit that had been chosen for her.
In the interim, she visited her boyfriend at weekends when things were going well between them.
Clare continued to attend the CAMHS and was prescribed anti-depressant medication which was given to her by her carer. She had recently quarrelled with her sibling and her social worker took them out for a day together which was successful in reconciling them.
Ultimately, both Clare and her social worker decided that the residential option would not suit her; she had found some introductory visits upsetting and it was decided that she would remain on a long-term basis with her carer, with whom she had formed a good relationship.
The final decision about this was confirmed at a meeting that she attended and she was reportedly happy about it.
The report also states that Clare's school later complained that they had not been fully informed about her placement arrangements.
Evidence from correspondence between them indicates that both the school and the SWD had difficulty communicating due to unavailability of staff in both services to take calls at the time they were made.
It reports that, sadly, Clare took her life a few days after the decision about her placement had been made.
The review's main "learning point" is that it is worth considering what the evidence on the placement of siblings demonstrates.
It cites research that indicates that contact with siblings often represents what children value most in family life. And says it is recommended that if siblings cannot be placed together, practitioners should reflect on what precisely this means for them, and do their best to facilitate the contact that the children want.
It says a recent Irish study reiterates the strong sense of sadness experienced by young people in care who are separated from siblings and highlights the responsibility of social workers to keep it on the agenda.