A letter to High Court Judge Peter Kelly from 15-yearold Kim O'Donovan four months before her death was never posted by staff at Newtown House, the investigation into the health board home reveals.
The report also reveals that a child at the now closed unit had his leg broken while being restrained, and that a girl was restrained by being held down on a table by five people.
The report makes it clear that the largely untrained staff was expected to cope with some of the most disturbed children in the State, in an unsuitable building and with little back-up from the psychological services.
The inspectors express concern that a letter which Kim O'Donovan had written to Judge Peter Kelly in April was never posted by staff. "The unit manager stated that the letter was not posted because its contents misrepresented the unit," it says. "A further reason given for withholding the letter was that the judge was not on the young person's contact list."
The investigation, conducted by the Irish Social Services Inspectorate, was ordered in August by the Minister of State with responsibility for children, Ms Hanafin. At the time, Kim O'Donovan, who had absconded from the home, was missing. Days later her body was found in a Dublin guesthouse. She died of a heroin overdose.
The report was ordered after complaints from the parents of another child at Newtown House. It was not specifically about the case of Kim O'Donovan.
It concludes that "there are a number of areas where Newtown House failed to meet the required standards for children's residential centres".
Newtown House, in Co Wicklow, was intended by the Eastern Health Board to be used as a specialised group home for younger children. However, in 1996, in response to demands by the High Court, it became a unit for children who, because of their needs and behaviour, could not be safely maintained in other children's residential centres. The children ranged from 10 to 17.
The report says that when Kim O'Donovan absconded, gardai were informed 25 minutes after she was due to be collected from her part-time job, that a description and photograph were given to gardai, that four other Garda stations and her mother were notified that evening, that staff kept in touch with gardai and that staff tried to find her themselves.
The report is critical of the use of physical restraint where a more sensitive handling of a situation could have removed the threat of violence.
One boy had his leg broken and, though the East Coast Area Health Board carried out an investigation, "the inspectors were told their request for a copy of the report cannot be considered until the staff member and his trade union have had an opportunity to respond".
In another case, where staff suspected a girl had a cigarette lighter because they had found cigarette ash in her room two days previously, she was asked to go into a vacant bedroom. "She was then requested to remove all her clothing and to hold a towel around herself, leaving a gap at the side of her body, so that staff could ascertain if she was hiding the lighter," the report says.
The report found that only a small proportion of the staff held suitable qualifications, that the building was unsuitable for the purpose to which it was being put, and that it could take six months to get an appointment for a child to see a specialist therapist.