Six months after Ciara Jobes' beaten, emaciated body was discovered in a Southeast Baltimore housing complex, the state agency charged with protecting children is only now forming a "work group" to find out what went wrong and why the 15-year-old had been left to die in the hands of a mentally ill woman.
"We had regular interaction with this child over time. Considering the outcome, things could have been done differently," said Maryland Human Resources Secretary Christopher J. McCabe, who oversees the Department of Social Services. "I'm not in a position where I can say which specific thing."
On Sunday, The Sun chronicled Ciara's short and tortured life, which was filled with warning signs that the girl was in danger. At least five public agencies had contact with the girl, but all failed to take decisive action to save her.
McCabe said he didn't form the work group sooner because "when things are public, it creates a greater momentum to look at it."
Satrina Roberts, Ciara's court-appointed guardian, is charged with killing the girl and could be sentenced to life imprisonment if convicted. Her trial is scheduled to begin next month, and she is seeking to be declared criminally not responsible because of mental illness.
Police say Roberts savagely beat Ciara, denied her food and locked her in an unfurnished and unheated room for months, forcing her to use a hole in the wall as a toilet.
By the time police found Ciara shortly before Christmas, her body had as many as 700 wounds -- most of them whip marks -- as well as signs of recent, violent sexual abuse. The girl, who was enrolled in Patterson High, had not been in school all semester.
McCabe said he hasn't established yet who will be on the committee or exactly what he is looking to accomplish with it.
"We simply are in the early formation of an internal working group," said McCabe, who has headed the Human Resources agency for five months. "I have no other information to provide."
The City Council also is trying to find some answers. The council's Judiciary Committee is holding a hearing July 10 with representatives of Social Services, the Baltimore school system and others.
"A young woman got lost in the system," said Councilman Keiffer J. Mitchell Jr. "How many other Ciara Jobes are out there?"
Maryland Attorney General J. Joseph Curran Jr. said at the time of Ciara's death that he would investigate the matter to see where the system failed the girl.
But Curran, whose office would represent the Social Services Department if the agency were to be sued, recently said he would not speak about the case until Roberts' criminal trial is over.
"I'm waiting to see how that turns out," Curran said. "Then we're free to make any analysis."
Ciara's life with Roberts began in 1998 when she went to live with Roberts at the request of the girl's mother, Jackie Cruse, who later died of AIDS.
The next year, Roberts -- who since 1995 had been receiving federal disability aid for a diagnosis of schizophrenia and bipolar disorder -- was rejected from the Social Services Department's foster care program.
A caseworker noted in her file that she had been cooperating with the foster program and her application looked promising, but Roberts abruptly stopped contact with the agency, resulting in termination of her application.
Two months later, in January 2000, the agency stood by silently when Roberts exploited a loophole in the system and persuaded a Circuit Court judge to make her Ciara's guardian.
Roberts' mental health was not checked by the courts or Social Services, because it is not their policy to do so.
Circuit Judge Joseph H.H. Kaplan, who granted Roberts guardianship at the request of Roberts, Ciara and her birth mother, said yesterday that checking the mental health of a prospective guardian would be "an invasion of privacy."
Likewise, Social Services spokeswoman Sue Fitzsimmons said yesterday that her agency has not made any changes as a result of this case, such as checking the mental health of foster parent applicants.
"We always go over our policies and procedures to make sure we're doing the right things," she said.
But child welfare advocates say the courts and Social Services are in desperate need of overhaul.
"Generally, there are at least three policy issues that require attention that scream out at you," said Assistant State's Attorney Julie Drake, who has handled child abuse cases in Baltimore for 10 years. "We see the same patterns over and over when children die. The reasons we're not addressing them is because we don't know about them."
Drake, who will prosecute Roberts, would not speak specifically about the case. She is on the city's Child Fatality Review Board, a group that meets monthly to review child deaths in the city.
Every month, she said, the board hears about 15 cases, most of them homicides.
Drake said the courts and the Social Services Department should ask all prospective foster parents and guardians whether they have been diagnosed with a major mental illness.
She also said the Social Services Department, which keeps all files confidential, should share its information with the public when a child dies.
"The policy is supposed to protect the child, but it doesn't," Drake said. "The child is dead at that point. The only person it protects is the person who made the bad decision."
And, she said, the stringent standards for becoming a foster parent should extend to the guardianship process, as well.
The foster process includes many applications and assessments, including a check of physical health and criminal background. To become a guardian, all a person must do is convince a judge that he or she would be a responsible caretaker.