Published: Oct 28, 2013 7:08 PM EDT
Updated: Oct 28, 2013 11:44 PM EDT

FORT MYERS, Fla. --- Officials for DCF, Children's Network and Lutheran Services all say the same thing, that the Michael McMullen case was their most difficult to date. Difficult not only because of the outcome, but because of the many mistakes that were made.

There is a list of mistakes the Department of Children and Families say workers made in the case of three year old Michael McMullen.
Michael died after his godmother, Donella Trainor, wrapped him in blankets, tied the ends with rope, and left him struggling for hours.
The first mistake?

Putting Michael and his siblings in the care of their grandmother, Gale Watkins, after reports of domestic violence between their mother and stepfather, Douglas Garrigus.

DCF called it an emergency placement, which meant only basic background checks were run.

"There was nothing legally to preclude her from getting those kids. The second issue is, she said all the right things, that she would take care of the kids, protect her grandchildren," said DCF Regional Head Mike Carroll. 

Instead, Watkins let the two stay in the house, and lied about him.

Second, no background check was run on Trainor, who was at the home during several home visits.

According to officials, several workers were on the case and each time Trainor lied about her name.
Still not one ran a background check which should have happened.

When asked if it could be a case of workers being overwhelmed?

"We try to keep the case load at a manageable level in our community however there is turnover and folks go to training, folks go on vacation," said Nadereh Salim, CEO of Children's Netowrk SWFL. 

Each case worker has about 22 children in their care.

Again, officials acknowledge there needs to be more training, and are not making excuses so they are now working on putting new programs in place.

They also said they are doing a review of cases involving about 300 children and circumstances similar to Michael's because again, families often lie and that's where things fall through the crack.

WINK News spoke exclusively to Karleen Halfmann and she says the whole system is struggling.

To put it into persepctive-she says her unit had six case managers with a little more than 200 kids. That's about 34 cases per case manager. But Lutheran Services argues they're doing the best they can.

"I wouldn't say struggling. This is really hard work and I am not making excuses," said Samuel Sipes with Lutheran Services.