They are the children who “fell through the cracks” — their too-short lives noted only after they are gone. Their tragic deaths from abuse or neglect — deaths that might have been prevented, should have been prevented — examined in minute detail for all the safety nets that gave way, the people who failed them.
This time that child was David Almond, a 14-year-old who “loved and was loved by his brothers,” who “found joy in making others laugh,” and who “could recite some SpongeBob episodes by memory.” So begins the report by the Office of the Child Advocate on his death last October, when he was found unresponsive in his family’s Fall River apartment, malnourished, weighing 80 pounds and with fentanyl in his system.
His father and his father’s girlfriend have been charged with second degree murder, but David was also a victim of “multi-system failure” by those agencies that should have protected him. Sure, the pandemic played a role, giving would-be abusers cover, but it was far from the only factor.
“Every single safeguard failed David,” said Maria Mossaides, director of the office, at the news conference that introduced the report.
That report also points the way to internal changes needed at the Department of Children and Families, and to possible legislative changes in the way decisions are made, and services offered, especially to those with disabilities (David was on the autism spectrum).
The task here — as it was back in 2008 when the Office of the Child Advocate was created in the wake of the tragic deaths of 4-year-old Dontel Jeffers at the hands of his foster mother in 2005; 11-year-old Haileigh Poutre, left comatose in 2005 after a beating by her adoptive mother; and the 2006 death of 4-year-old Rebecca Riley after being given an overdose of a psychotropic drug by her parents — is to protect children not just from abusive families but from bureaucratic neglect. All three families were being monitored by what was then the Department of Social Services.
The agency’s name was also changed — well, because that’s also what governments do when things go wrong.
Creating DCF and the Office of the Child Advocate didn’t stop the flow of tragedies. There were still the deaths of Jeremiah Oliver (2013) and Bella Bond (2015), perhaps better remembered as Baby Doe for all the months her body remained unclaimed and unidentified.
In the report on David Almond, the Office of the Child Advocate noted that DCF submitted 295 “critical incident reports” on 449 children and young adults (incident reports may involve more than one child) for the year ending June 30, 2020 — a 105 percent increase over the previous year. Such reports are required by law when a child in DCF care “suffers a fatality, near fatality, serious bodily injury or emotional injury.” That same year, DCF served 75,463 children and families.
That was, of course, mostly pre-pandemic.
From March 13, 2020, when David and his brother Michael were reunited with their biological father, until David’s death on October 21, 2020, he received only virtual DCF visits — the last just three weeks before he died — and no special education services from the Fall River school system.
It wasn’t just a crack David fell through, it was a chasm. And it won’t be fixed just because a few employees who should have known better or worked harder have been fired.
So how to close the chasm, repair that frayed safety net?
The Legislature’s Joint Committee on Children, Families and Persons with Disabilities has scheduled an oversight hearing for May 4 to try to answer that question. Mossaides can point them in the right direction — in fact, she already has.
“DCF currently has no policies, standard practices, or training curriculum about individuals with disabilities. The DCF Fall River Area Office did not understand Autism Spectrum Disorder,” she wrote, noting that since children with disabilities are at least three times more likely to be abused or neglected than their peers without disabilities, mandatory training for DCF staff was essential.
Ending bureaucratic stove-piping is also critical. Education officials and DCF, Mossaides wrote, “should collaborate and determine how districts should ensure DCF has access to regular attendance updates for all students who are in the legal custody of DCF.”
And a revamped reunification policy — to determine if children are to be returned to a biological parent — that includes an analytically sound safety and risk assessment and multiple case record reviews. That might have saved David’s life.
A Senate official told the Globe that a bill aimed at strengthening child protection laws, which failed to pass last year because of language differences between House and Senate versions, would probably provide the vehicle this year for making far more sweeping changes — after that oversight hearing.
Over the years, there have been too many names and photographs of the smiling young faces that came to haunt our consciences for a few short weeks or months. Then the hard work began of making things better, of fixing the system that let them fall through the cracks.
This is another of those moments. This is the debt that political leaders owe to David Almond.
Editorials represent the views of the Boston Globe Editorial Board. Follow us on Twitter at @GlobeOpinion.