Jersey's Health Minister failed to support a vulnerable child and its parents.
That is according to the States Complaints Board which has upheld a complaint made against a certain division of the Health and Community Services Department.
It said that it made no progress with supporting a vulnerable child 'until matters had reached a crisis point.'
That was despite the fact the child had been seen by a number of nurse practitioners within the division over a three year period.
One of the main problems the findings unveiled, was poor communication between the child's family and health professionals.
The Board heard that the family had had very limited access to professionals and there was no consistent record keeping by employees of the division.
It found that notes about the child had been taken in some meetings but not at others and that the parents had described their child as being 'moved from pillar to post with different members of staff.
They also discovered that the parents felt a sense of dislocation from their child's support.
The Chairman of the Board has said that it has recognised the vital work which the Service provides to countless children and their families on the island but mistakes were made in this case.
Mr Catchpole also set about reminding the Health Minister that while it is essential for his department to put children first, it must also extend its duty of care to 'patients, families and cares.'