An opportunity for three siblings to live together permanently with foster parents was lost because of "excessive bureaucracy" within a former health board, the Ombudsman Emily O'Reilly has said.
And in a tragic twist, an opportunity for the children to return to the couple collapsed when one of them decided she did not want to move from the residentional care unit she was in.
Ombudsman Emily O'Reilly said it appeared that after 10 years of being shuttled between foster care and residential care the child had become habituated to institutional living.
She told RTÉ radio: "So much time had elapsed that the window of opportunity had been closed. One of the children did not want to leave, she had become, I suppose institutionalised is a bit unfair, but she was happy where she was.
"The whole idea was that the siblings would be fostered as a unit or not at all and that was effectively the end of it."
In a preliminary report published today, Ms O'Reilly made a number of recommendations on treating potential foster couples in a "fair and proper" manner, which the Health Service Executive (HSE) has accepted.
She was investigating a complaint by a couple who wanted to foster the children whose mother had died in a car crash in 1997 and whose father declared himself unable to care for them.
The report maintained the anonymity of the parties involved, and referred to the complainants as Mrs Brown and her partner Mr Murphy.
The children had been moved between residential care and the guardianship of their aunt and uncle. Ms O'Reilly said the couple were entitled to regard an original arrangement as a long-term one. "This understanding was supported to a considerable extent by the social workers involved with the case," the report said.
She also found the board had not kept the couple sufficiently informed of proceedings. It had furnished them with "incomplete and erroneous information" over decisions relating to financial assistance for the children's care, which constituted a "serious failure in communication".
There was also a "serious breakdown in communications between the professionals involved" which led to confusion within the board.
"The couple were adversely affected by the above failures of the board, and both suffered extreme stress, anxiety and upset as a consequence," it added.
Among a range of recommendations was that the board arrange for the couple to be reassessed as foster parents to the children and €5,000 be paid to reflect the stress and anxiety they suffered.
Ms O'Reilly noted in her report: "Three young children are at the heart of this investigation, despite the fact that the complainants and those complained of are adults.
"It is now eight years since those children were placed in voluntary care following the tragic death of their mother, and the shuttling between relatives, institutional care and the part time and sporadic care of the couple began.
"Their early childhood is now over, one child has already reached adolescence and the other two are not far behind.
"My recommendations, which I believe to be fair and balanced, provide a possible opportunity to retrieve the situation before too much more of the siblings' childhood is gone."