It was around 6.30pm on 12 May 1998 and Tracey Fay had no home to go to. She was in a shopping centre on the northside of Dublin, in the company of a social worker who had been assigned to her case. Tracey had officially been placed in care that day. She was a few weeks shy of her 15th birthday.

Her mother, with whom she had a fractious relationship, was going back to England, to be with a partner who had been violent to both mother and daughter. Tracey was now officially in the care of the state. Naturally, she was fearful and nervous. The depth of her loneliness can only be guessed at.

An out-of-hours social worker was due to attend to Tracey that evening. Tracey had never met this person. She asked her assigned social worker to stay with her until the out-of-hours worker showed up. The social worker said this was not possible.

The report into Tracey's life and death does not document why it was not possible. Perhaps the social worker had adopted the nine-to-five mentality that infects some people employed by the state. Overtime would not be paid, so why should she give up her evening for the state? More likely, the social worker was stressed out, if not burnt out, toiling in a system stretched beyond all limits.

The social worker went home at 6.40pm. Tracey loitered for half an hour and then she began walking to Coolock garda station. Moving through the summer evening, detached from the late rush-hour crowd going home, going out, going somewhere, she was to all intents and purposes walking into the last phase of her life.

At a stage when most teenagers are bursting with the expectation of breaking out across new prairies, Tracey Fay was moving into a system that was incapable of arresting her flight towards degradation and early death.

The first signs that her life was at risk of substantial damage were spotted before she was a year old. Now, nearly 15 years later, little had been done to divert her from that destiny.

Even a first-class health system, designed and staffed to provide nurturing beyond the capability of parents, would have had difficulty with Tracey at that stage. But she wasn't entering a first-class system. What awaited her was a regime so damaged that it spends as much time attempting to protect itself as it does the children for whom it is supposed to care.

At Coolock garda station, Tracey was eventually introduced to her out-of-hours social worker, who later reported: "T presents as very nervous, unstreetwise, spoke of fears of being bullied."

By the end of that first month in care, the urgency of her situation was officially recorded.

"In summarising the situation as of the end of May 1998, the social worker wrote: 'T is an extremely vulnerable young girl whom at present is not receiving adequate care. It is imperative that she be given care and provided with the opportunity to develop herself and her talents and to have interests outside of her family'.

"During this month, T was referred to an area medical officer for treatment for scabies. The doctor stated that T did not have scabies but an allergy."

Over the next four years, Tracey Fay was moved from pillar to post within the care system. She never received the treatment that she required.

"There is no evidence on file that any of the staff in any of the services had been trained in Therapeutic Crisis Intervention or, if they had, there is no evidence of its use in addressing the violence that did present in T's behaviours while living in Orchard View or any other service," the HSE report states.

As she drifted further from the moorings that proper nurturing provides, Tracey's life began to spiral out of control. She was ejected from some of the HSE facilities because of her behaviour.

"Ultimately the staff at Parkview concluded that they could no longer cope with T's highly sexualised and provocative behaviour and that she must leave the service. Regrettably, the immediacy of both making the decision and implementing it on the same day, resulted in T being placed in a B&B service. It does not demonstrate a cogent interlinking of corporate health board responsibilities towards a child in care."

Tracey Fay's body was found in a coal bunker in Dublin's inner city on 24 January 2002. She had died of a drugs overdose.

Last Thursday evening in the Dáil, an emergency debate was held following the publication by Fine Gael of the HSE report into Tracey Fay's life and death. There were fewer than a dozen deputies present as children's minister Barry Andrews opened the debate. The empty rows reflected the priorities in the political system.

The details of the neglect of Tracey Fay's plight, from her first months to the end of her 19 years, are shocking, but should surprise nobody. Children at risk are simply not a priority. The cherishing of children at risk is a messy business, one that requires major resources and the dedication of serious minds at management level within the health system.

As things stand, there is a culture of crisis management in child protection services. A profound change to that culture can only come about through pressure, and there is no pressure to effect serious change that can save lives.

In May 2008, RTE's Prime Time illustrated the extent of neglect within the HSE in dealing with children at risk. In the wake of the programme, a column in this newspaper under the above byline made the following observation:

"Individual politicians make genuine attempts to tackle the scandal, but on the whole, government reacts to pressure. The only time pressure is applied in this area is when a case comes to public attention, usually through the violent deaths of children. Then, hands are wrung as everybody wonders how such an awful thing could happen. After a while, things settle down, the symptom is forgotten, lest we have to contemplate the disease."

No particular insight was required for such an observation. Two years later, we are there again, just as we returned after the deaths of Michelle Bray, Danny Talbot and Kim O'Donovan, all of whom died under the care of the HSE, and whose stories were briefly retold last week. The details of Tracey Fay's case will fade from public consciousness. At a political level, a few politicians will continue to make waves, but there will be no mention of Tracey Fay in constituency clinics. Your average rural backbencher is far more exercised about the drink-driving limit than the plight of children who have no experience of childhood.

Legislation is not the problem. The Childcare Act 1991 is a fine piece of work, obliging the state to provide properly for children at risk. Without the proper resources in place, the legislation is merely a piece of paper to be waved around courtrooms by lawyers. 'Children First: national guidelines for the protection and welfare of children' is a commendable document. Again, a copy might as well be used to light as a fire as to invoke rights. When the resources aren't there, the law is largely defunct.

Child protection is thus bracketed with mental health. Both are woefully neglected, mainly because the users of the service do not have a powerful voice of advocacy.

Through the years of plenty, many resources were ploughed into health. There have been some positive outcomes, particularly in cancer care and in accident and emergency. Both of these areas are the subject of political pressure. Both are frequently raised in constituency clinics. The hierarchy of priorities feeds into the system.

Child protection is not an immediate concern to voters when they attend with their local TD. So after a decade when the country was awash with money, some areas of the health system continue to operate at a standard that might be expected in a developing country.

Those who work within the child protection system have repeatedly pointed out how it operates. Case overload means that files thicken and mount up without being properly addressed. Early intervention, the most vital component of a care plan, is foregone because there are more immediate priorities. Cases are finally addressed when they reach crisis point. By then, it may be too late.

Further up the management chain, the priority is to cover asses. Decisions are continually long-fingered, which is what must be expected in any crisis-management environment.

The results are obvious. Children are failed by the state. Reports into children who die in state care are delayed in the hope that they might be forgotten. After all, the world outside has other priorities.

Within such as system, it is inevitable there will be avoidable deaths. Care for those who survive will also be completely substandard. The real results can be viewed through the decades in homeless shelters, addiction centres and the criminal courts.

Later this year, a referendum on the rights of children will be put before the people. The outcome will have implications for the constitutional rights of the child. But unless some urgency is injected into the health system, with a corresponding commitment to resources, little will really change for the Tracey Fays of this world.