THE TOP MASSACHUSETTS officials charged with protecting vulnerable children admitted Wednesday that the system failed badly in not preventing the death of Fall River teenager David Almond. 

It is clear to me and the leadership of this organization that the safety net we’ve been putting in place in this agency failed this child and failed this child in a significant way,” said Linda Spears, commissioner of the Department of Children and Families. 

Secretary of Health and Human Services Marylou Sudders said equally bluntly, “The safety net for our most vulnerable children failed this child.” 

The state Child Advocate Maria Mossaides on Wednesday releasea scathing report detailing the failures of DCF to protect David Almond, an autistic 14-year-old, who was killed in October 2020 allegedly by abuse and neglect perpetrated by his father John Almond and his father’s girlfriend, Jaclyn Coleman. The report found that the child protection agency made several inexplicable decisions and missed numerous warning signs that resulted in the abuse and neglect going undetected for months, as Almond and Coleman successfully hid David and his brother from child welfare authorities and school officials. 

Mossaides called it “a multisystem failure complicated by the pandemic” and a case in which “every single safeguard failed David.” 

In February, DCF moved to fire the two senior leaders at the Fall River area office. The clinical manager was terminated and the area director was slated for termination but retired.  

In a virtual question and answer session with reporters after the report was released, Sudders and Spears admitted to the agency’s failures and were unable to justify several key decisions made by DCF staff handling the Almond case.  

One question raised by the report was why DCF returned David and one of his triplet brothers, Michael, to the custody of their father and Coleman. Almond and Coleman had complied only minimally with a parenting plan required by DCF, a judge ruled Almond was unfit to parent, the couple did not have enough space for the boys, and service providers working with the boys at the group home where they lived and the special needs school they attended urged a delay. Mossaides called the decision to reunify the boys with their father “a serious error.” 

Spears did not disagree. “The circumstances in this case are inexplicable to me,” Spears said. “There’s no rationale that accounts for the decision to reunify these children given their risks and concerns for this family.” 

Another question raised by Mossaides was the decision not to classify David and Michael Almond as “high-risk.” That meant that during the early months of the pandemic, when only “high-risk” families were getting in-person visits from DCF, the Almonds received only monthly virtual visits. Mossaides said Almond and Coleman staged these visits so social workers only had a bad view through a cell phone of the boys, and Coleman was able to control what the boys told DCF. Because of this, DCF staff did not recognize how emaciated the boys had become. 

In hindsight, Sudders and Spears both agreed that the Almond boys should have been considered high risk. “We feel strongly this case was a case in which high risk should have been identified and in-person visits should have been conducted, regardless of whether or not the family worked to avoid visits,” Spears said. 

DCF was heavily scrutinized several years ago after a series of high-profile cases between 2013 and 2015 in which children died while under the agency’s supervision. Since then, the Baker administration has given DCF an additional $200 million, beefed up staffing by more than 650 positions, reduced social worker caseloads, and introduced numerous reforms.  

Sudders said staffing and caseloads were not an issue in this case. 

One major question that some observers posed even before the report came out was what role the pandemic played in weakening the institutions that were supposed to protect at-risk children. 

The report suggested that the pandemic was a complicating factor, but not the root cause of the failures.  

For example, the decision to reunify the boys with their father was made before the pandemic. But because they only moved into his apartment in March 2020, as the pandemic was breaking out, the boys never attended Fall River schools in person and never had any in-person visits from DCF. 

Had anyone seen the boys in person, given the state of their starvation at the time that the EMTs arrived to take them to the hospital, it would have been very evident that they were being starved to death,” Mossaides said. 

Mossaides said the pandemic “does not excuse the poor decisionmaking” that led to John Almond obtaining custody. But, she said, “I believe if we had not been in lockdown mode and those boys were able to go to school and to be seen in person by DCF social workers, that the stress that caused their behavior to regress would have been quickly identified, and I do believe appropriate action would have been taken by DCF.” 

Sudders said similarly that a lot of the decision-making took place before the pandemic, but the pandemic exacerbated the problems. “We would all acknowledge that the gold standard in child welfare is eyes on kids and as many eyes on kids as possible,” Sudders said. “And certainly the pandemic reduced the amount of eyes on kids.” 

Spears admitted that the core problems in this case were the “quality of decision-making” and the lack of oversight to ensure proper decision-making. Risk assessment tools and clinical team meetings were not used appropriately.  

“That didn’t happen, and that was well before the pandemic occurred,” Spears said. “The pandemic was a complicating factor in this case but not the fundamental cause.” 

State officials have committed to implementing all the recommendations made in the report. These include revising policies; better training social workers and supervisors; improving guidance around decisions about parental capacity, reunification, and safety; and reassessing practices around educational needs, children with disabilities, and virtual home visits.   

Gov. Charlie Baker, at a press conference in Quincy, echoed the appraisal offered by Sudders and Spears. “The report itself is incredibly damning of how that whole thing played out and very thorough,” he said, “and I expect and anticipate that everything in there is going to be implemented and it’s going to be implemented on a statewide basis and it’s going to get implemented as fast as it possibly can be.” 

DCF is already posting a job listing for a director of disability services. According to Spears, the agency already added a new level of review each time a child is reunified with a parent. It started using a new research-based tool meant to assess the risk of reunification.  

“We’ll work on every single one of the recommendations in the Child Advocate’s report,” Spears said. “They will be our Bible going forward in terms of how we do this work.” 

Most of the recommendations for DCF made in the report can be done administratively. But key lawmakers made clear that they will be looking at what role they can play. 

Rep. Michael Finn, who co-chairs the Committee on Children, Families and Persons with Disabilities, said the Legislature will convene an oversight hearing. 

House Speaker Ron Mariano called Almond’s death “a failure on the part of those who had a legal and moral responsibility to ensure his safety and wellbeing” and said the House “will review OCA’s recommendation and continue to improve any laws, regulations and oversight mechanisms in order to prevent another needless and inexcusable tragedy.” But Mariano suggested that the problem is not the need for new laws, but a lack DCF adherence to existing ones. “At the end of the day, this is a failure of all parties to abide by the laws that are currently in place,” Mariano said. 

Senate President Karen Spilka said in a statement, “The Senate is fully committed to listening to and working with stakeholders to address the numerous failures in the complex child welfare ecosystem to safeguard against this kind of tragedy in the future.”  

Lawmakers, in a provision in this year’s budget bill prompted by Almond’s death, already required school districts to collect information about chronically absent students during remote learning and document what efforts were made to reach them.  

The House has passed a bill to require more transparency about DCF processes. The Senate is still working on itso that could become a vehicle to add any additional provisions prompted by the Office of Child Advocate report.  

Mossaides said it is largely up to the Legislature which recommendations they want to enshrine in law. For example, lawmakers could require DCF to report back on how the agency is implementing particular changes. 

The report could also influence the work of a commission examining the state’s mandated reporting law. One systemic problem identified in the report is that Fall River school officials were hesitant to file reports regarding suspected abuse or neglect since they believed DCF was already working with the Almond family and aware of the problems. The mandated reporter commission is already considering recommendations to clarify the law related to how and when individuals working within an institution, like a school, are required to make a report to DCF. Any recommendations the commission makes will go to the Legislature.