As DCF answers for Fall River teen’s death, advocates see a ‘nightmarish cycle’ replaying

By the fall of 2015, a series of unimaginable horrors had shaken the Massachusetts’ child welfare system, from the death of 2-year-old girl whose body was found on a Deer Island beach to 7-year-old Hardwick boy who was starved and beaten by his father.

They fueled no fewer than a dozen reports over a two-year span, collectively saying the Department of Children and Families needed new policies, better-trained staff, and a continual flow of funding. The tragedies, read one Office of the Child Advocate report from that November, “taught us this lesson.”

Advocates question if it’s simply relearning it. Nearly six years later, DCF has been thrust back into the legislative and public crosshairs following the death of David Almond, an intellectually disabled Fall River teen who, authorities say, was starved and abused by his father and his father’s girlfriend while under the watch of the agency and others.

State lawmakers will attempt to get answers to how and why on Tuesday, when DCF Commissioner Linda Spears — who herself led a high-profile review of DCF before Baker hired her to lead it — and an array of public agencies testify in a highly anticipated oversight hearing into Almond’s death.

But many of DCF’s failures identified in the Office of the Child Advocate’s 107-page report are not just echoes but in some cases, nearly verbatim findings from other reports into child deaths and injuries both before and after Governor Charlie Baker took office in 2015.

David Almond.Office of the Child Advocate

They include accurately determining whether a child is in danger or DCF’s ability to review the quality of its own decision-making in the complex world of child welfare, according to a Boston Globe review of the findings. The repeated missteps are part of what one advocacy group called the “nightmarish cycle” buffeting the agency, even after years of new funding and reforms were supposed to help steel it against such high-profile lapses.

“When you think about those reports, you think about policy after policy recommendation. It’s different words, but it’s the same problem being addressed,” said June Ameen, the policy director at Friends of Children, which recently compiled a seven-year timeline of the various reports and problems they exposed.

“This is a billion-dollar organization with thousands of employees,” Ameen said. “A management team that was responsible for this kind of dysfunction [in another organization] would no longer be in existence.”

DCF, as well as some advocates, have defended the progress it’s made since a series of incidents shook confidence in the department in 2014 and 2015. The agency has added hundreds of social workers, whittled down their caseloads, and began releasing more public data. After years of budget cuts hollowed out the agency, department spending has jumped by nearly 15 percent over the last four years, pushing it over $1 billion.

The agency has said it already implemented changes amid the Office of the Child Advocate’s most recent probe, dedicating a team of employees in March to review every case of a child slated to be reunited with his or her parent with an emphasis on gauging the adult’s “improved parental capabilities.”

The “multi-system failure” that preceded Almond’s death, however, dredged up missteps that were all too familiar.

After the death of 2-year-old Bella Bond in the summer of 2015, investigators said DCF had missed multiple warnings the little girl was being neglected before her body was found on a beach that summer. In response, DCF was implementing a “robust system of quality assurance” to help review decisions and policy implementation, and retooling how it evaluates which children are truly at risk, according to an Office of the Child Advocate report then.

The same office urged exactly the same thing in March after Almond’s death, recommending DCF create a “robust quality assurance system” and noting that the report “mirrors concerns” from others. Employees hadn’t properly gauged how much risk the intellectually disabled 14-year-old faced, despite his father — similar to Bond’s mother — having a history of substance use issues and involvement with the child welfare system.

Managers handling Almond’s case also made a still-unexplained decision to reunite the teen and his brother with his father “without conducting any administrative review of the case record,” the report found.

A similar lapse was at the root of DCF’s failures in protecting Jeremiah Oliver, the Fitchburg boy whose body was found on a highway roadside in April 2014. Social workers in DCF’s area office had taken on his family’s case more than a year prior, but they never reviewed his entire case file and then failed to make regular visits to his home, the Office of the Child Advocate said at the time.

In the case of Jack Loiselle, a 7-year-old Hardwick boy, child welfare professionals — from teachers to counselors to DCF workers — had more than 100 contacts with his family over 10 months before he fell into a coma in 2015, starved and with bruises on his body. No one ever undertook a complete review of the case, according to DCF’s own internal review.

“Many of the recommendations that are in the David Almond report are redundant. They appeared in the Jeremiah Oliver case, they appeared in the Baby Bella review,” said state Representative Michael J. Finn, the House chairman of the Committee on Children, Families, and Persons with Disabilities, which is conducting Tuesday’s hearing.

“Part of what I’m trying to get at or understand better is, how are they enforcing the policies they already have?” said Finn, a West Springfield Democrat.

That DCF is again facing similar questions, however, is not a reflection of the progress it has made but rather the ever-evolving challenges in keeping 40,000-plus risk-children safe, according to other child advocates. Mary A. McGeown, the executive director of Massachusetts Society for the Prevention of Cruelty to Children, said unlike after other tragedies, DCF has made serious efforts to improve over the last six years, including increasing the number of adoptions and adding new specialized workers.

The Baker administration itself has referred to its effort as two “reform phases,” with an initial focus on stabilizing its staffing and then retooling the foster care system.

“If I could change this one thing, I think we should stop referring to it as ‘reforming’ the department. That suggests there’s going to be an end. Our child welfare system needs to be continually enhanced,” McGeown said. “DCF can’t solve this by itself.”

Beyond the reports’ specific findings, there are other struggles advocates say don’t often surface in tragedies but are no less devastating to some children. Children, on average, were staying 25 months in the state’s care as of last year, an increase from 2019 when it was already above the national average and second highest in New England, according to DCF’s annual report and an analysis by Friends of Children.

In 2019, 38 percent of children in Massachusetts foster care moved at least four times, an extraordinarily high rate of disruption to a child’s life, according to federally reported data. Only New Mexico had a higher percentage across the country.

“The problem is, kids who are suffering remain sort of invisible until the worst possible thing happens,” said Kate Lowenstein, the youth project director at Citizens for Juvenile Justice. “What do you measure when we’re not measuring death?”

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