The HSE is being urged to consider the admission guidelines for its mental health care services for young people.
It is after an investigation by an expert child protection panel into the suicide of a 15-year-old girl who was abusing drugs and alcohol.
The teenage girl, who has been given the name Niamh in today's report, was first referred to state services at the age of 14.
She had been found under the influence of drink and drugs, had an older boyfriend and a history of self-harm.
She had been attending an addiction service on and off before she was referred to Tusla and placed temporarily in foster care.
A counsellor said she needed full-time residential care to deal with her substance abuse but there are no in-patient addiction beds for girls her age.
After this, she was referred to hospital twice for emergency psychiatric assessment and was put on a waiting list for Child and Adolescent Mental Health services.
She died by suicide three months after her second referral without getting an appointment.
The National Review Panel (NRP) says the Department of Health and the HSE must take account of the need to provide services to young people who do not fit their guidelines for youth mental health services.
Speaking on today's executive summary report which reviewed the deaths of three children and young people known to the child protection system, Dr Helen Buckley, Chair of the NRP said: "On behalf of the NRP I wish to extend my sincere sympathies to families, friends and all those affected by the deaths of the children and young people reviewed by the National Review Panel, published today.
"The death of a child is an unthinkable tragedy and one which affects families, friends and communities.”
Referring specifically to the case of Niamh, Dr Buckley said: "One of the reports highlights the lacuna that exists where young people who are suicidal, with addiction and behavioural issues are not considered eligible for a mental health service.
"This service gap has been identified many times by the NRP and needs urgent attention from the HSE and the Department of Health.”
The two other cases which were identified in the report involved children, one male and one female, who died from sudden adult death syndrome.
The NRP reviews cases where a serious incident or death occurs of children or young people under 18 who are in the care of the State or have been known to the Child and Family Agency’s social work department or funded services.
