Dating back almost a decade, there were complaints and investigations involving Dr. Earl Bradley, a well-known Delaware pediatrician who authorities say may have molested more than 100 children.
There were jokes among colleagues, who thought Bradley had an unusual practice with his carnival-like office filled with toys and a merry-go-round. Even Bradley's own sister, who worked for him, heard parents' concerns.
Despite the warnings, Delaware's medical board only recently suspended Bradley's license — after he was arrested.
"The system failed. What I don't know, and what we must find out, is where and how," said Delaware Gov. Jack Markell, who plans to order an independent review of the state's handling of the case.
Outraged parents have complained that children could have been spared had officials acted sooner.
"If he was under investigation for over a year, why didn't someone speak up?" a tearful mother said at a community forum last month. "All of this could have been avoided."
Bradley, 56, is being held in lieu of $2.9 million bond after being charged with more than 30 felonies, including rape. After years of suspicions, his arrest came when a 2-year-old girl told her mother that Bradley hurt her last month when he took her to a basement room after an exam.
Authorities have said Bradley videotaped some of the attacks, some of which occurred in exam rooms with Disney themes.
Bradley faces a preliminary hearing on Thursday. His attorney, Eugene Maurer, did not immediately return telephone messages left at his home and law office Saturday.
The case has shocked the close-knit coastal community of Lewes and the central Delaware town of Milford, where he closed an office in 2005 after police investigated him. The case is even more chilling because some alleged victims are no more than 6 months old.
The governor is not the only one calling for a review. The state attorney general's office also has asked for an investigation.
What they are likely to find is a lot of fingerpointing, but few willing to accept much, if any, responsibility.
For example, officials who oversee the Board of Medical Practice claim they never received any complaints until after the arrest. State law requires all medical professionals, state agencies, and law enforcement agencies to report to the licensing board in writing within 30 days if they believe a doctor is or "may be" guilty of unprofessional conduct.
State police said they didn't notify the board of a 2008 investigation because they worried about jeopardizing their case. The attorney general's office was involved in a 2005 investigation, yet apparently didn't tell the board.
Milford police said they tried to file a complaint with the board in 2005, but were rebuffed by an investigator who told them it needed to come from the victim or her parent.
Even two pediatricians interviewed in 2005 told investigators about complaints from Bradley's former patients.
Dr. Lowell Scott told police he referred to Bradley as a "pedophile" when talking to colleagues.
"I probably shouldn't comment on that. ... We would refer to him that way as more of a joke," Scott told The Associated Press.
"We all felt that he practiced differently than we did. ... None of us had any actual knowledge of him doing any potential harm," Scott said.
Bradley was described as a quiet, unkempt man who had trouble looking adults in the eye but nevertheless gained parents' trust. Police allege that after finishing exams at his Lewes office, he would molest children in the basement or an outbuilding, where they would be given toys or candy.
Scott said he never had any proof, only accusations.
"You're talking a 3-year-old against a 50-year-old. I figured if there was something behind it, then the police would lead to the medical board," he said.
Bradley's own sister, who worked for him as an office manager, told police she had complained to two officials with the state medical society, but again, nothing came of it. The society officials deny receiving any complaint from Linda Barnes.
Barnes told police in 2005 that her brother was bipolar and taking medication from the office, and that several parents had complained to her about Bradley inappropriately touching patients.
An initial review by Attorney General Beau Biden's office indicates a prosecutor recommended the 2005 matter be referred to the medical board, but there is no evidence that his agency notified the board.
"That's part of what I've asked the state solicitor to review," Biden said.