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Avalena Conway-Coxon died suddenly in foster care in Auburn on a hot Saturday in August.
Avalena Conway-Coxon died suddenly in foster care in Auburn on a hot Saturday in August.

The two little girls who were found unresponsive in Auburn this summer were living in a foster home that should never have been licensed and entrusted to a foster mother who had repeatedly been accused of neglect, according to a harsh report released Thursday by Governor Charlie Baker.

The report, which detailed failures at almost every level of the Department of Children and Families, confirmed that 2-year-old Avalena Conway-Coxon, who died, and 22-month-old Samara, who remains hospitalized, suffered from heat stroke and had bruises that suggested that they may have struggled to get out of car seats.

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No one has been charged in the case, which remains under investigation, but Baker said two DCF workers had been placed on administrative duty. Officials said the workers, a manager and a social worker who has been with the department for 25 years, could be disciplined or fired.

“The report made clear there were many instances of blatant lack of oversight by DCF staff,” Baker said, striking a familiar tableau as he stood with his two top child welfare officials to grimly review the details of a child’s death for at least the third time in the last several months. “The failure to recognize and report certain issues with this foster home and parent is unacceptable.”

The review, done by DCF staff, was released as authorities confront the cases of two more children who may have died while under the agency’s watch.

A 4-month-old boy who was found unresponsive in a Lynn homeless shelter Saturday had been the subject of two previous neglect reports to DCF, according to an official with knowledge of the investigation.

Police are also investigating the death Monday of a 2-year-old girl in Worcester whose family was being actively monitored by DCF, according to the Worcester Telegram & Gazette, which quoted the girl’s uncle.

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While the precise circumstances surrounding the death in Auburn remain a mystery, the report provided several clues as to what might have happened in the hours before the foster mother, Kimberly Malpass, called 911 on Aug. 15 to report that Avalena and Samara were unresponsive.

According to the foster mother’s boyfriend, Anthony Mallet, an alleged drug addict with a criminal record, Malpass had gone out drinking with her friends the night before.

When Malpass returned home, she was drunk and vomiting, and she and Mallet argued, he later told an investigator. He said he took two Xanax tablets out of her pocketbook and went to bed. He woke up the next day, he said, when he heard Malpass screaming, and left the house before police arrived.

Malpass told investigators that she had put Avalena and Samara in their beds for a nap at 10 a.m. and, when she went to check on them between 11:30 a.m. and noon, she found them unresponsive. She said she called 911 and carried them downstairs. The report said, however, that there were conflicting accounts about whether Malpass found the children after their naps or whether they were found on the living room floor.

Both girls were probably exposed to high temperatures for a prolonged period of time, according to the report. A doctor who examined them said they may have been left unattended in a hot room or in a car. Temperatures that day were in the 80s.

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When Samara was brought to the hospital, she was dehydrated and suffering from seizures and respiratory failure. She remains in a rehabilitation hospital; officials would not discuss her condition other than to say she is “stable.” A third foster child who was taken from the home, Samara’s 6-month old sibling, was not injured.

The report faulted DCF for licensing Malpass as a foster parent in March 2014, despite receiving two prior reports that she was neglecting her own children — two of them biological and one adopted.

The most serious report came in 2012. It accused Malpass of verbally threatening and swearing at her children and alleged that one of the children had welts after being hit with a belt by her boyfriend. That report also said one of her children was chronically absent from school and that the family was known in the Auburn school system for “intergenerational neglect.” Yet there is no record that DCF workers ever considered those allegations when they licensed Malpass as a foster parent.

The other warning came in 2008, when DCF received a report alleging “deplorable conditions” in Malpass’s home.

A DCF investigation at the time determined that her home was not in poor condition. But Malpass told DCF that she suffered from a long list of health problems, which the report said should have triggered warning flags years later when she applied to be a foster parent. She said she had lupus and gout, took Xanax nightly, was disabled, and had suffered from kidney failure since age 12.

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There is no indication DCF took these conditions into account when they reviewed whether she was suited to care for three young foster children, in addition to her own three children, one of whom has special needs.

The report said a doctor for one of Malpass’s children had told DCF during the licensing process that Malpass was overwhelmed with her own children’s medical needs, but the agency never followed up.

The licensing process also violated DCF policy in other areas, the report said.

DCF workers never properly examined Malpass’s home, and erroneously concluded it had enough room for six children. After approving her license, a DCF worker then missed three of the six required visits to the home, the report said.

Malpass cared for nine foster children over 18 months.

In March, after both Avalena and Samara had been placed in Malpass’s care, DCF received a report alleging that Mallet was living in the home and was hitting another of Malpass’s foster children, a 3-year-old.

Mallet’s presence in the home was a violation of DCF policy, which requires any frequent visitor to pass a background check. After receiving the complaint, DCF ran a check, which revealed he had a criminal record, and concluded he was probably living in the home, despite claims to the contrary by Malpass and Mallet. The report said that DCF, at this point, should have increased oversight of the family, but it did not.

Baker said Thursday that as he continues to pursue a broader effort to fix DCF, the department would also retrain its workers to license foster parents and reassess foster homes in the Worcester area, to ensure they are safe.

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“I do not want to be another administration . . . that chases what I would describe as a half-baked solution to this problem, and hopes it all eventually goes away,” he said. “We want to be the folks who actually stick with this all the way through, and get it right.”

Listen to Governor Baker’s remarks below:


Michael Levenson can be reached at mlevenson@globe.com. Follow him on Twitter @mlevenson.