A report's found a four-year-old boy with serious disabilities was left in hospital for over two and a half years, despite being cleared for discharge.
An investigation into "Jack's case" by the Ombudsman for Children's Office has discovered failings by the HSE and Tusla.
Jack, which isn't his real name, suffered brain damage and other life-changing injuries following a car crash abroad in 2016.
He need 24/7 care and was immediately admitted to the hospital when he arrived home in Ireland.
Despite doctors clearing him to be discharged in 2017, Jack remained living in various hospital settings for two and a half years.
The Ombudsman for Children's Office was alerted to concerns about how long it was taking for the HSE to come up with an exit plan for him.
Its report has found the actions of the HSE and Tusla had a negative impact on the boy's life - and that Tusla's conclusion that Jack's needs were solely a matter for the HSE was discriminatory on the grounds of disability.
The investigation also found systemtic failures by the HSE to provide adequate support and services to children like Jack with disabilities who are living in inappropriate settings.
Children's Ombudsman Niall Muldoon says the report makes for grim reading and that far reaching recommendations have been made so children across Ireland aren't impacted by any of these issues again.
