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A series of government agencies, buffeted by the COVID-19 pandemic, failed to protect or properly monitor a 14-year-old intellectually disabled boy before he died in October — starved, with fentanyl in his system, and in a cramped apartment where his supposed caretakers had long hid his abuse, according to a state investigation into his death.

The “multi-system failure” within the Department of Children and Families, the Fall River public school system, the state’s Juvenile Court, and with the teen’s own father — now charged with second-degree murder — stretched back months, if not years, according to the Office of the Child Advocate, before police said they found David Almond unresponsive in the one-bedroom Fall River apartment filled with hundreds of baggies with heroin residue.

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The office’s 107-page report into David’s death reveals a complicated and tragic situation, in which a boy once described as vivacious and the “mayor of his former school” all but receded from public view and later died weighing just 80 pounds.

The failures, the Office of the Child Advocate found, were compounded by the holes opened in the state’s safety net by the onset of the pandemic, but also not adequately explained by it.

Officials at virtually all levels didn’t act on a bevy of warning signs, including the fact that David never did any schoolwork between March and October, the child advocate’s review found. DCF officials also made a series of admittedly “inexplicable” choices before March to put David in the custody of his father, John Almond, and his girlfriend, who officials say then purposely tried to hide the neglect and abuse of the teen and one of his brothers, Michael, from social officials and others.

“We had — I hate to use the term — but the perfect storm for a family who wanted to hide themselves,” Maria Mossaides, the director of the Office of the Child Advocate said. “That does not excuse the poor decision-making that happened. . . . Every single safeguard failed David.”

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David and Michael were two of triplets, all diagnosed with autism, and they both lived with a half-brother, referred to as “Aiden.” Their third triplet brother, referred to as “Noah” in the report, had refused to live with his father and was staying in congregate care at the time of David’s death.

DCF, the agency charged with protecting the boys, “failed to put all the clues . . . into a clear picture of the reality of the life” that the boys were living, according to the report.

The decision by DCF officials to even allow David and Michael to live with their father and his girlfriend, Jaclyn Marie Coleman, by March 2020 — days after Governor Charlie Baker declared a state of emergency — was never explained by DCF officials, the child advocate wrote.

All four boys had been removed from the couple’s care in 2017, and DCF had set a goal for them to be adopted. But officials in DCF’s Fall River office suddenly reversed course in July 2019, with a goal of returning them to the couple’s custody — despite John Almond being deemed “unfit to care” for the triplets just a day earlier in Juvenile Court, according to the report.

Despite concerns from the boys’ congregate care provider, two of the triplets returned to their father’s apartment on March 13, 2020.

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The state’s Juvenile Court and the attorneys representing the caretakers and the children did not question DCF’s decision, and while the boys had a history of involvement with child welfare officials in New York and Massachusetts — including being removed from their father’s care at least four times by 2017 — DCF staff did not identify the family as being “high-risk,” according to the report.

As a result, DCF officials never visited the boys in person between March and the time of David’s death in October, and even in monthly virtual visits, Coleman “always directed [David] on what to say,” according to the investigation.

Baker, whose administration oversees DCF, said Wednesday that David Almond’s death “was preventable.”

“There was a series of systemic breakdowns over a long period of time,” he said, adding that the report is “incredibly damning” and that state officials intend to act on changes the child advocate recommended. “It’s going to get implemented as fast as it possibly can be.”

DCF officials said Wednesday that the agency fired the Fall River office manager as a result of the case and that another manager was slated to be fired but retired first. A spokeswoman said the department is also creating a new position of director of disability services.

Linda Spears, DCF’s commissioner, said she couldn’t explain several of DCF’s decisions, including not flagging the family as high-risk or changing the boys’ tracks from adoption. She said the agency failed to catch efforts by Coleman and John Almond to hide abuse.

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“The pandemic was a complicating factor in this case but not the fundamental cause,” Spears said.

Baker campaigned in 2014 on overhauling DCF following a series of tragic child deaths, and since taking office, has ordered a slew of policy changes, added 300 social workers, and sought to drive down the number of children each agency worker is responsible for, a historically stubborn challenge.

State officials said caseloads were not a factor in David Almond’s death.

But DCF has long wrestled with other issues. For example, federal officials said in November that the agency had repeatedly discriminated against parents with disabilities, and must reshape its policies so to not rely on “unsupported stereotypes.”

House officials said Wednesday that the Legislature’s committee on children and families would hold an oversight hearing on the case, though when is unclear. “It’s time for DCF’s leaders and others to step up, be transparent, and take action to address this failure,” House Speaker Ronald Mariano said.

Though the boys enrolled in Fall River public schools, school staff never saw or spoke with David or Michael between March, when they were scheduled to begin school, and David’s death seven months later.

David was ostensibly attending school virtually, but he never performed any work. And while school officials “raised red flags” about his participation, they never filed any reports of suspected neglect or initiated truancy action, the child advocate found.

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“Many of these persons . . . acted as if DCF involvement relieved them of any obligation to take further steps to investigate the safety of the children,” according to the report.

A Bristol Country grand jury on Friday indicted John Almond and Coleman on second-degree murder and neglect charges stemming from David’s Oct. 21 death. They have pleaded not guilty.

Mossaides’s office also made a series of recommendations, including that DCF conduct a review of its own practices, including the services it provides disabled children.

The Department of Elementary and Secondary Education also should create standards for what actions districts should take when children fail to attend school, she said. And Mossaides urged the Juvenile Court, as well as attorneys, to play a more active role, including requiring that DCF update the court on the clinical needs of the family at each court date.

“Everyone needs to be aggressive at questioning the DCF decisions,” she said.


Matt Stout can be reached at matt.stout@globe.com. Follow him on Twitter @mattpstout.