Officials say her adoptive father sexually abused her, and now years later, her adoptive mother, a onetime case worker and adoption specialist, is accused of helping rape, torture, murder and dismember her.
The repeated abuse against Grace has many questioning the integrity of the child welfare system.
"Whether it's Grace or other children, I think we are starting to realize, what many of us in the system already know, we are not a child-centered system," said Cathleen Palm, founder of the Center for Children's Justice.
The organization looks to inspire systemic improvements to the welfare system.
"The only way we really protect children is for people to believe the child welfare system can work," Palm said. "It does work for many children, but we have to start to send a message of, here's what happened in the Grace Packer case, here's what was challenged, but here's also what's good about all the other times we helped kids through the child welfare system."
On Friday, the Pennsylvania Department of Human Services confirmed four agencies that worked with the Packer family prior to Grace's death this summer: Berks County Children and Youth, Lehigh County Children and Youth, The Impact Project, and Pinebrook Family Answers. Police and the Lehigh County District Attorney's Office investigated 2010 allegations against David Packer for sexually abusing a teenage foster child and Grace. He was convicted and served more than a year in prison.
"We really need to understand the systems that intersected with her, what their role was, and if there are any cracks in those systems that would potentially jeopardize safety of any child," Palm said.
That same year, Sara Packer lost her job as an adoption supervisor with Northampton County Children, Family and Youth. According to the Department of Human Services, that's also the year Sara was terminated as a foster parent after taking 30 children in over a ten year period.
Officials haven't answered why Sara Packer lost her job or why she was terminated as foster parent.
When David Packer was convicted and sentenced, Sara Packer continued to have legal care of Grace.
"How do you make sure that child continues to be safe inside of that environment, and did everyone inside that home get access to a forensic interview, medical exams?" Palm said.
It's not clear if Sara Packer knew anything of the abuse. She was not charged. Lehigh County District Attorney Jim Martin previously told 69 News it may have been a situation where Sara "had some awareness of it and failed to act on it."
"Often times we think well resolve this by removing the party who sexually assaulted her, that might be enough. is that environment still a safe environment for her? What about she potentially has that constant lingering of, did anyone else know?" Palm said
According to Palm, another aspect of the system that should be assessed is oversight.
"The state really needs to look at whether or not we are served best by having an independent child advocate or ombudsman office for people to ring the bell, raise the flag higher, to say we're concerned about what this may mean for them," Palm said.
She also added that without independent oversight of the welfare system, reporters of child abuse, or victims themselves, may feel powerless.
"Children who are in foster care, who are adopted, are often the most vulnerable and most voiceless kids you're ever going to find," Palm said. "So imagine, that someone picked you up, took you from your own home, and said you're not safe here, we're going to put you somewhere else. Now, if you begin to experience sexual or physical violence in that house, it's hard to believe you have any place to call, because the very place you might call may be the system itself that put you there"
Palm said the Jerry Sandusky child sex abuse scandal put focus on to reporting abuse. She says now, the focus needs to be on whether or not those reports are being adequately followed up on.
"If we don't start paying attention to whether the system responds in a way that's effective to protect kids, then the person making the report, has only done so much, because the system isn't responding in the way the children need the system to respond," Palm said. "We really need to look at what happens after those calls, not just immobilize everyone to make the calls."
In addition, Palm said there are questions as to whether or not welfare workers are properly trained and given sufficient resources to do their jobs.
Palm went on to say more information needs to be revealed before a full assessment of the system can be done.
"Biggest challenge now is we are getting drips and drabs of information, and with every little drip, it erodes the public's confidence," Palm said.
Palm added people looking to harm children can figure out how to manipulate the system to do so.
"Often times a case opens your eyes to things you didn't think of," Palm said. But she added change isn't always the best course of action. "It is always dangerous to change policy on one case."
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