WHAT A TWISTED, dreadful irony it is to call Satrina Roberts the "guardian" of young Ciara Jobes.

For almost three years Ms. Roberts had custody of Ciara. According to police, she isolated the girl and locked her up. She beat her and she starved her.

And at the age of 15, weighing 73 pounds and covered with bruises, Ciara died. A detective who saw her body said, "This kid was treated worse than an animal. She was nothing but skin and bones."

A skin-and-bones teen-ager who apparently died of neglect and malnutrition and God knows what else in a house with a grownup and a full refrigerator. If ever a child needed a guardian it was Ciara. By all accounts, she got a monster instead.

How could this happen in a civilized society? In the middle of a city? Where were her parents? Where were her friends? The neighbors? The state? The teachers? The cops?

It would almost be a relief to point a finger, pin the blame. To say that this one person or that bureaucracy was responsible for the grim fate of Ciara. But the failures that shaped her short, sad life and appalling death were manifold, having only one common thread: Adults failed Ciara Jobes.

She was born to Jackie Mae Cruse and Irvin Lee Jobes. Her mother, now dead of cancer and AIDS, was neglectful (another of her babies died of a cocaine overdose). Her father was absent. Her first decade was spent in and out of juvenile court, until a judge finally put her under the care of Ms. Roberts, a family friend. What a terrible mistake.

She had two grandmothers, but they didn't see her often. There were no caseworkers to check on her; since Ms. Roberts was named her legal guardian she was not a ward of the state.

When she stopped appearing in school, administrators sent a letter home. Then another. They thought Ciara was a truant, and summoned Ms. Roberts to court, but she didn't show up. Ciara certainly couldn't have shown up: Police say she probably was too weak to walk.

Neighbors knew there was a girl in the apartment, but knew little more. People have their own lives to live, after all.

Ms. Roberts has been charged with murder and assault, her "guardianship" over. But now, how do we as a society protect the potential Ciaras out there? It is a vexing question with no easy answer.

On paper, Ms. Roberts must have looked like a reasonably responsible individual. Apparently she had no criminal record, and no complaints had been registered against her with the Department of Social Services. Of course, to Ciara Jobes' dying day, no complaints were registered.

When the courts transfer legal guardianship from a parent to someone else, social service caseworkers are not routinely involved. Perhaps they should be, if only to make a home visit or two. But in a department already stretched too thin over too many kids, such an added burden could prove impossible without jeopardizing even more at-risk children.

Clearly, though, the court that hands over a child to a "guardian" has a fundamental responsibility to ensure that the best interest of that child is being served. That did not happen here. At the very least, the court and the state's agencies assigned to protect children must review Ciara's tragic case and repair whatever crack she fell through.

Meanwhile, it's up to the rest of us. To the neighbors and teachers and long-lost relatives. Even to the strangers who may see something amiss as they pass by. Because one child lost - and so horribly lost - is one child too many.