DCF does not always report critical incidents to the Office of the Child Advocate (OCA). We gave OCA detailed i-FamilyNet case notes on 40 incidents that appeared to us to meet OCA’s definition of “critical incident.” OCA officials determined that although 13 of these cases were not reportable critical incidents, at least 16 of them met its definition of “critical incident” and should have been reported to it by DCF. These 16 cases included incidents of stabbing, rape, assault with a baseball bat, gunshot wound, and suicide attempt by fire. OCA officials told us that based on the available records and case notes, it could not definitely determine whether the remaining 11 cases met its definition of “critical incident.” However, according to the descriptions of the medical services these children received, these 11 incidents appeared to involve serious bodily injury such as sexual abuse, suicide attempts, and physical assaults, and therefore we believe they met OCA’s definition of “critical incident.”

Without proper reporting by DCF, OCA cannot perform its oversight function to ensure that children receiving DCF services are appropriately cared for.

Authoritative Guidance

OCA’s definition of “critical incident” is drawn from Section 1 of Chapter 18C of the Massachusetts General Laws. Section 5 of Chapter 18C requires DCF to inform OCA when a critical incident has occurred.

Reasons for Noncompliance

DCF’s internal reporting requirements for critical incidents do not mirror OCA’s requirements. Specifically, DCF’s Guidelines for Reporting Critical Incidents to Central Office require DCF employees to complete a Critical Incident Form for three categories of occurrence that must be escalated internally: fatalities, near fatalities, and central office alerts.7 This form does not include “serious bodily injury” and thus is not aligned with the OCA reporting requirements or the law noted above. DCF’s process of reporting to OCA has two steps, and if the first step of internally reporting a critical incident is not completed, DCF’s central office cannot review the incident and, if appropriate, report it to OCA.

There is also lack of centralized written policies, procedures, controls, and monitoring activities that provide the area offices with the necessary oversight over the process of reporting critical incidents.


  1. DCF should establish a single consistent standard for defining and reporting critical incidents that matches the General Laws.
  2. Based on this standard, DCF should develop policies, procedures, controls, and monitoring activities that allow for adequate oversight of the reporting of critical incidents.

Auditee’s Response

DCF responded as follows:

The Department’s primary responsibility and mission is to ensure the safety of children. DCF respects the role the Office of the Child Advocate has to accomplish within the Commonwealth. DCF takes its reporting obligation to the Office of Child Advocate earnestly and agrees with the OSA’s recommendations that our critical incident reporting process needs to be simplified and streamlined. The Department would like to note however that the “reporting up” of incidents to regional, central office or even to the OFFICE OF THE CHILD ADVOCATE does not change the intensity or ferocity by which we ensure children are safe from harm and families receive the needed supports. The “reporting up” provides additional opportunity for review of the case and helps identify practice improvement activities. To that point, DCF is developing a revised streamlined “Central Office Incident Notification” (COIN) form and process for area offices to report to central office all incidents of concern (critical or otherwise). We are also developing guidance for the area offices on when and how to complete and submit the form. This new process will allow DCF Central Office to more easily identify the subset of incidents that meet the criteria of a “critical incident” that need to be reported to the Office of the Child Advocate. DCF is actively working with the Office of the Child Advocate to develop the specific criteria on which incidents are to be reported as critical incidents in accordance with the requirements of the current law as amended by the Legislature after the period under review.

The Department was aware of each of the incidents cited by the OSA and took action to ensure the safety and well-being of the child(ren) involved. As discussed with the OSA, every incident needs to be examined on a case-by-case basis to determine which rise to the level of a “critical incident.” Without reviewing the specific details of the case, it is impossible to determine whether an incident is a critical incident or not. DCF Central Office reviewed the details and case documentation for each of the 40 incidents cited and believes it reported appropriately the required critical incidents to the Office of the Child Advocate. DCF reviewed our findings with the OSA for each of the incidents in question. As a further step, DCF will review each incident with the Office of the Child Advocate to ensure our interpretation of critical incidents was appropriate based upon the details of each incident.

In addition, OCA gave us a written response regarding critical incidents:

The issue of Critical Incident reporting is one that [OCA] is continuing to work on with the child serving agencies, including the Department of Children and Families. As your report highlights, it is complicated and insuring consistency in reporting is a goal of this office.

In the explanation of Critical Incidents, the draft audit states that a “near fatality” can only be designated as such by a hospital staff member and the life threatening condition is a result of physical abuse, sexual abuse or neglect. The Department of Children and Families has adopted the [Child Abuse Prevention and Treatment Act] definition as its guide in determining a “near fatality.” The Office of the Child Advocate has the statutory authority to define “critical incidents,” and we will continue to refine the circumstances where we would expect to be notified if a child receiving services from any state agency were to suffer a near fatality, regardless of the cause of the injury or medical determination.

We will continue to work with the Commonwealth’s child serving agencies to ensure that the expectations of the OCA are clear and that the agencies are complying with those expectations.

Auditor’s Reply

We acknowledge that the investigations conducted by DCF are a critical component of the Commonwealth’s system of ensuring child safety. However, we cannot minimize the importance of DCF making sure that it reports all critical incidents to OCA. It is OCA’s responsibility to monitor the actions DCF takes to address all cases of child abuse and/or neglect to ensure that DCF effectively meets its own responsibilities in this area. Without complete critical incident information, OCA cannot effectively meet its mission of ensuring that every child involved with state agencies in Massachusetts is protected from harm and receives quality services.

Further, contrary to DCF’s assertion, it did not appropriately report critical incidents to OCA in all cases in which it was required. As stated in our report, we shared information about the 40 cited incidents with OCA, which has the statutory authority to define “critical incident,” and OCA stated that it believed at least 16 of the 40 incidents were serious enough to be considered critical incidents. Although we do not dispute that DCF may have taken the actions it deemed necessary to ensure the safety of the children in question, informing OCA of all critical incidents is a key component to this child safety process.

Based on its response, DCF is taking measures to address our concerns in this area.

7. According to DCF’s Guidelines for Reporting Critical Incidents to Central Office, “A Central Office Alert is any situation, which is NOT a child fatality or near fatality, that may draw the attention of the media and/or requires that the Deputy Commissioner and the Director of Public Relations be informed of the situation.”

Date published: December 7, 2017