Ten years after 2-year-old Bella Bond’s death exposed flaws in child welfare oversight, Massachusetts still struggles to act on its own risk assessments.
In 2022, a Worcester family was identified as “very high risk of future maltreatment” by a Massachusetts Department of Children and Families (DCF) tool. But earlier this year, a 4-year-old girl was killed after intervention fell short, officials claim.
The Office of the Child Advocate’s (OCA) latest report criticizes DCF for ignoring its own tools, undercutting specialists and failing to adjust plans as risk escalated. And now OCA is calling for accountability.
What happened to A’zella Ortiz?
A’zella Ortiz died on Oct. 15, 2024, after police were called to her home for reports of a child who was unresponsive after falling on the floor.
Her father, Francisco Ortiz, 34, told officers she fell off a kitchen table. Despite life-saving measures at the scene by officers and paramedics, she was later pronounced dead at a hospital.
Police said the girl had multiple bruises, which Ortiz claimed were caused by falling after climbing on a chair and table. Two other children in the home were also found with numerous bruises and appeared malnourished and dehydrated, according to court documents.
Francisco Ortiz has been charged with murder in connection with A’zella’s death.
The Ortiz family had been served by DCF between 2018 and 2023 for a total of three years and eight months due to findings of neglect of A’zella and her two siblings.
OCA, an independent state agency, found that DCF missed warning signs and closed its case a year before A’zella was killed. The report states that DCF failed to reassess the children’s chronic neglect and missed warning signs in the children, such as untreated developmental delays, as two of the children were nonverbal. There were also several missed pediatric and specialist visits, the report found.
Accountability for DCF decisions
One of those warning signs came after a risk assessment tool identified “very high risk of future maltreatment” in October 2022.
It was the highest score possible on the risk assessment tool.
After the risk assessment, DCF staff took the next steps by consulting with DCF clinical specialists. And the specialist issued “several recommendations that directly related to the concerns identified in the family’s risk assessment score, including offering family child care and in-home support and stabilization services.”
During the family’s time under DCF oversight, a clinical specialist was consulted twice. But each time, the recommendations were considered non-mandatory and treated as guidance for DCF case management teams.
And the parents “refused to engage in the services identified to support the family and alleviate risk in the home,” the OCA report states.
Despite the high risk identified by the tool, nothing further was done. OCA stated that the value of the specialist was “undercut by sporadic use and non-adherence to the recommendations.”
“Despite the escalation in risk to the children and the parents’ refusal to engage in services to alleviate that risk, the DCF case management team did not reevaluate their clinical formulation of the family to determine if alternative support or intervention was required to successfully engage the family in reducing risk to the children,” the report states.
OCA points out that recommendations from case consultations are hindered by their design as the clinical specialists have no direct case management responsibilities and there is no way to ensure their guidance and recommendations are followed, “nor is there a requirement or expectation that a DCF clinical specialist will follow up on their own recommendations to learn whether their advice was helpful to the DCF case management team or to the family.”
“As a result, both consultations had little to no impact on the DCF case management team’s involvement with the Romero Ortiz family,” the OCA report states.
OCA’s suggestions focused on “the lack of follow-through and accountability,” adding that DCF policy should be updated to strengthen the role of the specialist and expectations, including feedback loops.
Follow the recommendations, DCF developed a desk reference to educate clinical teams about using Central Office Specialty Units. And in January, DCF will begin a monthly distribution of more robust information on high-risk cases. The information is for managers and will allow them to more easily identify high-risk cases and address concerns with clinical teams.
Long-delayed DCF tools to protect children
DCF is still working on implementing tools identified after the death of Bella, and again after the deaths of David Almond and Harmony Montgomery.
The idea of a risk assessment tool first circulated in a 2015 report after the death of Bella. DCF did not properly assess Bella’s risk or her mom, Rachelle Bond’s, ability to parent, closing the cases early, a report stated.
The idea of a Structured Decision-Making (SDM) tool was further identified as a need in 2021 after the death of 14-year-old David Almond, who died on Oct. 21, 2020. He and his brothers were under the supervision of the New York Office of Children and Families (OCFS) from 2013 to 2016 until the state returned them to John Almond’s custody in 2016.
A year later, they were removed from the home after DCF started investigating the family for substance use and abuse and neglect of the children. But once again, they were returned to John Almond on March 13, 2020.
The decision to reunify the children with their father was a “serious error” compounded by the COVID-19 pandemic, OCA said.
On Oct. 21, 2020, police were sent to 107 Green St. in Fall River for a report of an unresponsive person and found the boy bruised, emaciated and living in abhorrent conditions, authorities said. He was rushed to Charlton Memorial Hospital, where he was later pronounced dead.
Although Harmony Montgomery’s story unfolded before the COVID-19 pandemic, there were similarities to David’s. Harmony died in 2019 after being reunited with her father in New Hampshire.
A report after her death stated that Harmony’s needs, well-being and safety were “not prioritized” in considering her custody placement.
One of the ways to fix this for the future was to create a Structured Decision-Making (SDM) tool to help with assessments.
The system, created by Evident Change, works by identifying the key points in a child welfare case and uses “structured assessments to improve the consistency and validity of each decision.”
“The model consists of several assessments that help agencies work to reduce subsequent harm to children and to expedite permanency,” the website states, adding that its system has been more reliable than any child protective services assessments.
It was identified as a need in 2021 after the death of David Almond, and the design was expected to be completed in September 2022. Training was expected to then take place and be completed by June 2023.
The deadline was postponed after talking with Evident Change to make the tool more impactful, according to DCF.
Training on the Structured Decision Making (SDM) Danger and Safety Assessment tool, a component of the SDM Reunification Assessment, finally began in May — about three years after the need was identified. And the training is expected to take multiple months in order to make it sustainable for staff. Training will include DCF leadership, managers, social workers and legal staff from 29 local DCF offices, five regional offices and the central office.
That part of the training was expected to be completed by December 2024.
The next training for the full SDM Reunification Assessment was targeted to begin in May 2025. That was then expected to be fully implemented in late 2025.
As of December, 3,500 DCF staff have been trained on the SDM Danger and Safety Assessment tool. It is expected to be formally incorporated into practice in January. At that point, staff will be required to use it during all investigations.
But the implementation of the full Reunification Assessment SDM tool is still underway, and additional training is needed.
The full implementation is expected in Fall 2026 — more than a decade after a “Baby Doe,” who was found in a trash bag — later identified as Bella — was killed.
