Despite multiple warning signs that a 7-year-old Hardwick boy was being starved and beaten by his father, the state Department of Children and Families never recognized the full extent of the abuse until the child fell into a coma in mid-July, according to a devastating report released Friday by Governor Charlie Baker.
The boy had lost 12 to 15 pounds and had bruises across his body and burns on his feet, even though he was being monitored by 16 DCF workers and eight behavioral health counselors, as well as a neuropsychologist, medical providers, teachers, a guidance counselor, and other school personnel, the report said.
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The internal review conducted by the Department of Children and Families found that the child-welfare professionals had more than 100 contacts with the family between last September and July 14, when the boy fell into a coma and his father called 911. No one ever undertook a complete review of the case, it stated.
The father, Randall Lints, has been charged with nearly killing his son, identified as Jack Loiselle. Jack remains in a long-term care facility. The father remains behind bars.
The report blamed multiple failures for DCF's inability to protect the child from harm. Baker said, however, that no one would be disciplined or fired and that the state agency would instead update its policies to ensure similar cases are more carefully reviewed by DCF staff.
"The easy thing to do would be to fire someone over that," the governor said. "The hard thing to do would be to fix the policy, and then hold people accountable to it."
Jack's case is the latest in a string of tragedies that have raised questions about the competency of DCF. By month's end, Baker is planning to release a review of the agency's handling of a case involving a 2-year-old who died and a 22-month-old who was found in critical condition in a DCF-licensed foster home in August.
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In that case, the foster mother and her children were being monitored by 10 DCF supervisors, managers, and front-line case workers, one of whom had visited the home in Auburn just three days before the mother discovered the children were unresponsive and called 911. The 22-month-old remains in dire condition, officials have said.
"I'm not going to stand here and say there are no systemic issues here," Baker said Friday. "I'm going to stand here and say we are in the process of dealing with an agency that has many systemic problems, and we're going to fix them."
In Jack's case, the report catalogued in painful detail the boy's troubled history. He had been raised by his grandmother almost since birth, and there were no reports of abuse or neglect until a judge in the state's Probate and Family Court Department granted Lints, 26, custody of the boy in June 2014.
The report found that DCF staff and the courts were not fully aware Lints himself had been abused as a child and monitored by DCF until he turned 18.
Had the caseworkers looked in DCF's database, they would have discovered that Lints had threatened his siblings with a knife, been diagnosed with bipolar disorder and attention deficit hyperactivity disorder, and, as a boy, had been "locked in his bedroom without any food or furniture" and "forced to sleep on the floor and urinate in his closet."
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That documented history, the report said, would have triggered immediate concerns about his ability to care for Jack, who was also kept in his room and denied food and water to stop him from urinating on the floor. Baker said DCF staff will, in the future, routinely examine the agency's records for previous histories of abuse or neglect.
The agency first received reports that Lints was abusing the boy late last year, when the department was warned he was forcing his son to wash his urine-soaked clothing with bleach and that Jack's skin was cracked and bleeding. DCF decided not to intervene, however, because Jack was already working with behavioral health counselors.
It wasn't until February that DCF began officially monitoring the boy, after it received a warning that Jack had been shivering for two days and his hands were purple because he'd been forced to wash urine off the floor with cold water.
The gravest warning about Jack's safety came from a therapist who contacted DCF on May 18.
The therapist told the agency that Lints was withholding food and water from his son and "noted that Jack looked a lot thinner."
The therapist told DCF that Lints had gone camping with his girlfriend, her children, and Jack. But Jack had not been allowed to participate in activities and had to sit in a corner. The therapist also reported that Lints had boarded up the windows in Jack's room "so he could not look outside" and had threatened not to send his son to school, "knowing that Jack loved school."
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The therapist urged DCF to remove Jack from his father's care and "explained that not once in her entire career had she told DCF that a child should be removed from the home," the report said.
A DCF social worker relayed the recommendation to a supervisor. But the supervisor opted to keep the boy in the home, pointing out that another counselor had reported the father was "actively working on the concerns," and others had given "positive reports" about Lints.
Such dramatically conflicting accounts of the boy's well-being were a hallmark of the case.
School officials, the report said, regarded Jack as pleasant and respectful. But Lints told DCF that he was oppositional and defiant and would bang his head, fight, and play with matches.
On June 29, two weeks before Jack fell into a coma, a DCF social worker reported that the boy "was the happiest she had ever seen him." The social worker saw Jack eat a bowl of soup and drink water and juice and did not notice any bruises.
About a week later, on July 8, a newly assigned caretaker called DCF with a different assessment. That person expressed concerns about "controlling behaviors" by Lints, and worried that Lints was exaggerating his son's disciplinary problems.
The next day, July 9, another counselor had a more upbeat report and said Jack had been eating and was "alert, personable, and engaging." This was the last known contact the state had with the boy before he fell into a coma five days later, the report said.
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Baker said DCF policy would be changed so that high-level supervisors will automatically review cases in which there are conflicting reports about a child's condition.
"There was a lot of debate going on, you can tell that reading the report," Baker said. "But nobody, clearly, had a 100 percent look at the child."
With so many professionals monitoring Jack, DCF probably had a "false sense" the boy would be safe, said Marylou Sudders, the state's health and human services secretary, who joined Baker at the press conference.
The report also criticized the court's decision to hand custody of Jack to Lints, pointing out that the boy did not know his father.
Baker said that in future custody cases in which a parent has had no involvement with a child, the courts should appoint an independent advocate, called a guardian ad litem, to determine whether the new family arrangement is in the child's best interests.
Michael Levenson
can be reached at mlevenson@globe.com.