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On her last night at a Lockport group home, Tina Marie Douglas tossed her few possessions in the trash and warned caregivers that she planned to run away in the morning.

It was not an idle threat. In the last three months, the 48-year-old state ward diagnosed with psychiatric and intellectual disabilities had slipped out of the home eight times and repeatedly run into the street. Her caregivers were considering moving her to a different home, one on a block with less traffic.

But that never happened. Shortly before dawn in October 2013, she broke away again, sprinted down a four-lane state road and was fatally struck by a car.

The Illinois Department of Human Services, which licensed the group home, assigned its inspector general’s office to conduct a comprehensive review.

But a Tribune investigation found the inspector general’s staffers never interviewed a witness, never visited the group home, never left their desks. Instead, they relied on group home employees to help investigate their own business and, based on those findings, determined the home was not at fault.

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