A review of case records and interviews with officials and others familiar with the investigation show a system in discord. Among the failures was the licensing of the Ciambrones as foster parents despite agency concerns about Mrs. Ciambrone's young age and her ability to handle children with emotional and behavioral problems. There was also a failure to investigate and document abuse reports regarding the Ciambrones, including one from a pediatrician who diagnosed a different child in the home as malnourished. A third failure was allowing the Ciambrones' adoptions of Lucas and his sister to occur without a detailed study of the home environment, as required by agency policy. A fourth failure was related to the high turnover in the agency's county office, resulting in no single person having an overview or familiarity with the case. Further, personnel in the system allowed Mrs. Ciambrone, a manipulative woman determined to get her way, to undermine the decisions of frontline caseworkers who had reservations about the Ciambrones' parenting competence. This article traces the details of the case from Lucas' birth up through the pretrial hearings of the Ciambrones.