Press Release  Massachusetts Child Advocate Releases Child Fatality Investigative Report

Boston, Mass. — The Office of the Child Advocate (OCA) released findings and recommendations Wednesday following a multi-system investigation into the death of David Almond, a Fall River teenager, last October.

David Almond and his triplet brothers were each diagnosed with Autism Spectrum Disorder at an early age, and due to abuse and neglect, were under the consistent supervision or care of the New York Office of Children and Families (OCFS) from 2013 to 2016.  New York authorities returned the triplets to John Almond’s custody in 2016, and he brought the triplets to live with him, his girlfriend Jaclyn Coleman, and his mother in a small one-bedroom apartment in Fall River, Massachusetts.  In less than one year, the Massachusetts Department of Children and Families (DCF) began investigating the family for substance use and abuse and neglect of the children.  In October 2017, DCF removed the triplets and a younger half-sibling from the home.

In early 2020, the triplets were living at a group home in Massachusetts when DCF initiated the process to return them to Mr. Almond and his girlfriend, who continued to live in the same one-bedroom apartment in Fall River that the triplets were removed from in October 2017.  The decision to reunify the children with their father and his girlfriend was a serious error that was compounded by the pandemic.  While one of the three triplets opted not to return to Mr. Almond, David and his brother, Michael, returned on March 13, 2020.  The Governor declared a state of emergency due to the COVID-19 pandemic three days later.  On Oct 21, 2020, Fall River emergency personnel responded to the home, where they found David emaciated, bruised, and unresponsive.  Michael was also suffering from similar indications of abuse and neglect.  Both were taken to a nearby hospital where David was pronounced deceased. Michael was hospitalized for several months but survived his injuries.  The younger half-sibling was also in the home but appeared uninjured and physically unharmed.  Mr. Almond and Ms. Coleman are currently facing criminal charges.

In accordance with state laws, the Office of the Child Advocate investigates the actions and inactions of state agencies following any serious injury or death to a child who is receiving state services. Through a detailed investigation, the OCA identified several key findings relative to this case:

• The DCF area office decision to return the boys home was not clinically justified and failed to address the children’s special needs and safety.
• Mr. Almond and Ms. Coleman minimally engaged in the services required to support reunification; DCF area staff did not evaluate whether Mr. Almond or Ms. Coleman’s behavior and skills had improved to be able to parent children with autism. The Juvenile Court and the attorneys representing the caretakers and the children did not question DCF’s decision to return the children nor did they insist that a careful reunification plan be developed and approved by the Court prior to return.  
• The COVID-19 pandemic exacerbated the situation by preventing in-person services and visits. Mr. Almond and Ms. Coleman continuously circumvented contact with DCF area office staff, the Fall River Public Schools, and other human service providers. DCF area office did not adequately assess the effect that the pandemic had on this family, especially in light of the family’s history of abuse and neglect. 
• DCF area office staff did not identify the family as being “high-risk” for future abuse or neglect, which would have required in-person home visits during the pandemic.  As a result, David and Michael were never seen in-person and instead were visited only virtually between March 2020 and David’s death in October.  The DCF high-risk criteria that was issued during the pandemic to identify families that required in-person visitation did not specify a child’s disability as a risk-factor.
• DCF area office staff missed many warning signs that David and Michael were in distress.  For example, Mr. Almond and Ms. Coleman prevented the boys from attending any in-person or remote school, did not allow service providers to see or speak with David or Michael, and often prevented the boys from answering questions when they were seen virtually once a month by social workers. During one DCF virtual home visit, a visible wound on David’s face was seen by social workers and dismissed by Ms. Coleman as self-harm. Service providers raised concerns about the lack of engagement and what appeared to be the boys’ regression in function.
• Fall River Public Schools (FRPS) failed to provide David and Michael with a free and appropriate public education between March 2020 and David’s death in October 2020 because neither David nor Michael received any academic instruction or related special education service. The FRPS failure to provide David and Michael with the education they were entitled to is a direct result of the complexities of the COVID-19 pandemic.  

The OCA has determined that there was a multi-system failure, complicated by the pandemic, and that the safeguards that were in place, especially at DCF, were inadequate.  As a result of this investigation, the OCA has highlighted the need for changes, some of which will require legislative action and others that will require policy and procedure changes at the departmental level.  Examples include:

• DCF redesigning their reunification process to include more rigorous safety assessments and evaluations of parental capacity.  Furthermore, during emergencies similar to the ongoing COVID-19 pandemic, there is a need for a protocol that more accurately identifies which children need be physically (rather than virtually) visited on a routine basis.
• DCF conducting a comprehensive review of their own practices related to how services to individuals with legally-identified disabilities are assessed and provided.
• DCF improving its quality assurance infrastructure to provide additional levels of qualitative monitoring and to create feedback loops that promote a culture of continuous learning. 
• The Department of Education (DESE) creating operational standards for addressing school attendance and the actions school districts must take when children fail to attend school.
• School districts explicitly linking attendance in remote and hybrid models to the actual participation of students in their education and the following of all established policies and procedures for investigating and addressing attendance issues. 
• DESE and DCF collaborating and determining how districts should ensure DCF has access to regular attendance updates for all students who are in the legal custody of DCF.
• The Juvenile Court playing a more active role in analyzing the merits of a proposed reunification case, including the requirement that DCF link the family’s action plan to the clinical needs of the family. Furthermore, the Court should more strictly ensure that the circumstances that led to DCF’s original decision to remove children from their home are completely resolved before allowing reunification to occur.

“We feared when this pandemic began, that families would experience economic, social and other stressors, and that vulnerable children would suffer from lack of interaction with trusted adults, and that is tragically what happened in this case. David Almond was a vivacious, smart, and fun-loving boy who was often described as the ‘mayor’ of his former school.  His impact on those who worked with him and loved him was profound and everlasting,” said Maria Mossaides, Director of the Office of the Child Advocate. “Child welfare professionals have the most difficult job - one that is filled with challenging decisions and trying circumstances. We need to strengthen our systems so that the missteps that occurred in this case are never repeated.  While there is nothing we can do to bring David back, we do have the opportunity to honor his memory by making permanent changes that will protect other children.  My office is committed to ensuring that this important work takes place.”

The OCA expects that the appropriate corrective actions that the public agencies will undertake in the wake of David’s passing will improve services for all children in the Commonwealth.  In the coming months, the OCA will work with the public agencies involved in this case, Governor Charlie Baker and  the state legislative leadership to expeditiously implement the recommendations listed in this report. The OCA will continue to monitor and to report on the progress of the implementation efforts.

About the Office of the Child Advocate

The Office of the Child Advocate (OCA) was established in 2007 as an independent agency and represents the commitment of the Governor and the Legislature to improve services to children and families in the Commonwealth. Our mission is to provide independent oversight of state services for children to ensure that children receive appropriate, timely and quality services, with a particular focus on ensuring that the Commonwealth’s most vulnerable and at-risk children can thrive. Through collaboration with public and private stakeholders, the OCA identifies gaps in state services and recommends improvements in policy and practice. The OCA also serves as a resource for families who are receiving, or are eligible to receive, services from the Commonwealth.

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