Illinois Department of Children and Family Services Director George Sheldon's resignation on Thursday was both necessary and inevitable.
Not simply because of the death of Joliet 1-year-old Sema'j Crosby, but because of the failure of the agency, throughout its many visits to her home, to recognize and act on the issues outlined in a 22-page report released by the agency on May 26.
Many factors led to Sema'j's death, starting with her home environment. DCFS has limitations, in budget and because it handles nearly 1,600 concurrent cases and has been accused and sued previously for unnecessarily separating families.
That, however, does not excuse the grave problems that regularly occur in reporting cases, as outlined in the Sema'j report.
Case files are destroyed, filed late and given separate case file numbers at the same address, eliminating the possibility of finding a pattern through the 11 reports filed related to Sema'j's home.
The report also outlined that the home was in severe disrepair. An anonymous caller said that up to 30 people were living in a three-bedroom, 864-square-foot space designated by Section 8 housing rules to only be for Sheri Gordon and her immediate family. Drugs were openly sold at the property and a nearby playground, estimated to be 25 yards from the home, where the young children were often sent at all hours of the day.
Case workers suspected Gordon was being taken advantage of by other family squatting at the home. At some points, the report documents, the young children of those family members were left in charge of Gordon's children.
Gordon even misrepresented to a case worker which children at the home were her own in one incident.
The sad fact was that case workers also understood that Gordon "appeared to have cognitive limitations that interfered with coordinating the children's medical appointments and care."
Gordon and the family also lacked transportation to get the children to appointments and money to pay for prescriptions.
This included Gordon not being able to appropriately understand the care for her 7-year-old son, Sema'j's brother, who was hospitalized for suicidal thoughts on three separate occasions between September and the final report the day after Sema'j's death.
He did receive special education while attending a therapeutic day school.
Through all of this, reports were not combined to give the agency and investigators any sort of perspective on the problems at the home, and no real action was taken.
After Sema'j's death, her brothers were sent to foster care.
Now DCFS will have a new leader, and the agency will need to learn from the recommendations in the 22-page report of Sema'j's case.
If those changes occur, it won't make up for the failures in Sema'j's case, but it could become one positive in a case that has shown nothing but negatives to this point.