Scathing report details DCF failures leading to death of Fall River boy
14-year-old David Almond died of abuse and neglect while under state oversight
THE DEPARTMENT OF CHILDREN AND FAMILIES failed autistic teenager David Almond time and time again, making inexplicable decisions and ignoring danger signs until the 14-year-old died, emaciated and bruised, allegedly at the hands of his caregivers.
A damning report issued Wednesday by the Office of the Child Advocate turns a harsh spotlight on the state’s child protection agency, highlighting problems that were exacerbated by the COVID-19 pandemic, but are not entirely due to it.
“We feared when this pandemic began, that families would experience economic, social and other stressors, and that vulnerable children would suffer from lack of interaction with trusted adults, and that is tragically what happened in this case,” said child advocate Maria Mossaides.
David Almond’s father, John Almond, and his girlfriend, Jaclyn Coleman, are now facing second-degree murder charges in his death.
The case follows a string of deaths in recent years of children under state oversight that led to promises of reform and the infusion of more than $200 million in new funding for the state child welfare system.
Gov. Charlie Baker, at a press conference in Quincy, called the report “thorough and hugely distressing,” and said it was clear that the loss of David Almond’s life was preventable. “The report itself is incredibly damning of how that whole thing played out and very thorough and I expect and anticipate that everything in there is going to be implemented and it’s going to be implemented on a statewide basis and it’s going to get implemented as fast as it possibly can be,” Baker said.
What happened to David Almond?
DCF head admits agency failed David Almond
DCF spokesperson Andrea Grossman said the Department of Children and Families fired the Fall River area clinical manager as a result of the case. The Fall River area director was slated for termination but retired.
“The death of David Almond is heartbreaking and the Department mourns for him,” Grossman said. “Immediately following his death, the Department of Children and Families took action to address critical issues raised, including urgently reviewing internal policies and practices to reduce safety risks for children… The Department is in the process of evaluating the report and will act on the OCA’s recommendations.”
The report also identifies problems in the state education department and Fall River public schools, the juvenile court, and the probation service that contributed to Almond’s ability to fall through the cracks of every institution tasked with protecting him.
State Rep. Carole Fiola, a Fall River Democrat, said the report shows something was “severely wrong.” “There’s so many organizations, there’s so many hands in the pot that have a role in this,” Fiola said. “How could so many systems fail a family and a child?”
Rep. Michael Finn, a West Springfield Democrat who co-chairs the Committee on Children, Families and Persons with Disabilities, said the Legislature will convene an oversight hearing and is committed to enacting reforms. “While the Covid-19 pandemic has certainly made all of our work more difficult, it in no way explains or alleviates the obligations to protect the most vulnerable children which is our responsibility to do,” Finn said in a statement. “We are even more deeply distressed by the systemic failures that have occurred at each agency whose responsibility it was to protect David, for they have failed him.”
David Almond was found unresponsive when the Fall River police were called to his father’s home on October 21, 2020, and he was pronounced dead at the hospital. His triplet brother Michael was found, also emaciated. A three-year-old half-brother, referred to in the report as Aiden, was physically unharmed. A third triplet, referred to as Noah, was not in the father’s custody at the time. (Noah and Aiden are both pseudonyms.) The apartment was in deplorable condition, and substances believed to be heroin and fentanyl were found there.
John Almond and Coleman were indicted by a Bristol County grand jury last week on charges of second-degree murder and neglect of a disabled person resulting in serious bodily injury.
The 106-page report detailed months in which David and Michael were abused, as their father and his girlfriend tried to hide them from the authorities. While other agencies that could have protected the boys left their case primarily to DCF, the state agency – which conducted only virtual visits to the family due to the pandemic – ignored numerous danger signs.
“DCF, the agency explicitly charged with protecting these children, failed to put all the clues provided by the family’s history, service providers, school officials, the children’s own presentation, the screened-out allegations of abuse and neglect, and Mr. Almond and Ms. Coleman’s own actions, into a clear picture of the reality of the life that David, Michael, and Aiden were living,” the report concluded.
The facts of the case, laid out in the report, provide a trail of missed chances to intervene.
For years leading up to David Almond’s death, the family had a lengthy history with child protective services. The triplets, originally from New York and all of whom had autism, had been in the legal custody of New York’s family services agency, which removed them from their parents’ home three times before 2016. John Almond moved to Massachusetts in 2013, and in September 2016, a New York family court awarded him custody of the triplets, for reasons that remain a mystery.
The triplets moved to Fall River, where John Almond was living with his girlfriend, Coleman, and his mother, Ann Shadburn, all of whom had their own histories of involvement with child protective agencies.
Nine months later, the family was first brought to DCF’s attention in Massachusetts due to allegations of abuse and neglect. The children were removed from the home in October 2017 due to allegations of neglect and physical abuse, parental substance use, unsanitary conditions, and excessive school absences. They were placed in a congregate care setting that specializes in caring for children with autism.
In 2019, after John Almond and Coleman made minimal progress in complying with any parenting plans, the goal for the children was set as adoption. Yet months later, the DCF Fall River office changed the children’s goal for back to a return to their parent. The decision was made apparently based on a parenting evaluation by an outside service provider, despite Almond and Coleman’s minimal participation in services required by DCF and despite a Juvenile Court judge’s ruling that John Almond was unfit to parent.
In December 2019, Fall River area office managers at DCF began the process of returning the children to Almond and Coleman. The decision was made, the report writes, without any familiarity with the case or any administrative review, without consulting with the triplets’ service providers, and despite Almond and Coleman facing eviction if the triplets were to live with them because the one-bedroom apartment was too small for seven people.
The first time the triplets spent the night with Almond and Coleman, Noah was involved in a physical altercation and returned to his congregate care program late at night. Noah refused to return to their house, but the incident did not affect planning for David and Michael’s return. DCF case managers, the residential group home where the triplets were living, and the special needs school they were attending requested a longer transition period, expressing concerns that the boys were being moved too fast, resulting in a delay by DCF managers only until March 2020.
Despite extensive interviews and reviews of the case, the Child Advocate wrote, “The [Office of the Child Advocate] could not deduce, and no DCF personnel were able to articulate, any clear reason why David and Michael were reunified with Mr. Almond and Ms. Coleman.”
According to the report, from the time David and Michael Almond returned to Almond and Coleman’s home on March 13, 2020 until David died, Almond and Coleman “took active and persistent steps” to keep David and Michael out of sight of DCF, their school, and other services providers to hide their abuse and neglect of the boys.
With DCF transitioning many services online due to the pandemic – COVID restrictions went into place days after the boys were returned to their father’s care – Almond and Coleman repeatedly said technology problems prevented them from meeting with service providers.
Even when Coleman expressed concerns about safety or revealed worrying details about their lives –when she said John Almond physically restrained David due to David’s aggression or reported that David was sick from eating snacks and lying in his own vomit – DCF either failed to follow up or Coleman was offered services, which she declined. Coleman routinely controlled what the children said to DCF.
DCF continued to conduct only monthly virtual home visits despite numerous danger signs, including David’s hospital emergency room visit for an injury Coleman said was self-inflicted, other reports of injuries, cancelled service appointments, David’s skipped physical, and an anonymous report that Shadburn, John Almond’s mother, should not be living with the boys because of her criminal history.
Coleman prevented David from seeing his therapist, and did not let Fall River school staff see the boys. She refused to participate in a DCF visit outside their home, saying John Almond had been exposed to COVID-19.
Although DCF had the ability to conduct home visits when a family is considered “high-risk” for abuse or neglect, DCF area office staff never identified David Almond as high-risk. Mossaides said the decision not to classify David Almond as high-risk was “one of the major errors in this case.”
The last virtual visit occurred September 25, 2020, three and a half weeks before David died.
Among the problems the report identified: DCF failed to gather sufficient information from other service providers about the adults’ progress; did not identify their substance use as a focus; changed the triplets’ goal to reunification without proper reason and rushed into the reunification despite numerous concerns; improperly screened out a report of neglect; ignored concerns about Shadburn; did not recognize the family was using technology as an excuse to avoid service providers; did not provide David with necessary services; and lacked a basic understanding of autism.
While the pandemic did not cause the problems, the report found DCF did not recognize the challenges posed by COVID-19 and did not rethink its decision to reunify the children with their parents at a time when they would be unable to receive the in-person individualized support they needed.
The report includes extensive recommendations for policy changes at DCF, including revising multiple policies; better training social workers and supervisors; improving guidance around decisions about parental capacity, reunification, and safety; and reassessing practices around educational needs, children with disabilities, and virtual home visits.
DCF says the department reviewed its practices after Almond’s death. The department is creating a new position of director of disability services to support social workers and supervisors in cases involving children with disabilities. It is retraining staff on assessing child safety risk and parental concerns, including substance use.
The report also identified problems with the Fall River school district and the Department of Elementary and Secondary Education, primarily related to its COVID-19 response. David and Michael transferred to the public school district just as schools were closing due to COVID, so they never physically attended school or spoke to a teacher. Their father opted them into remote learning, but David failed to engage online.
The Fall River district did raise concerns about the David’s lack of participation, but teachers never spoke to David directly and did not file a report of abuse or neglect, although district officials were in touch with his case managers at DCF. The school did not offer David services over the phone or in paper packets. Meanwhile, the state education department did not establish clear guidelines for how school districts should handle high-needs students who opted into remote learning or how to identify abuse under those circumstances.
The report also finds fault with the Juvenile Court, which oversaw the Almonds’ case, and the Probation Service, which was supposed to monitor compliance with court orders.
Between 2013 and 2015, the Office of the Child Advocate conducted three similar comprehensive reviews of deaths of children under DCF custody amid high-profile cases. Since 2015, the Legislature and Gov. Charlie Baker’s administration have increased funding for DCF by more than $200 million, beefed up staffing by more than 650 positions, reduced caseloads, and introduced numerous reforms.
The latest case is likely to raise questions about what good that money has done. DCF says some of the reforms recommended by the Child Advocate’s report are already underway.Fiola, the Fall River state representative, said she looked through the older investigations and “some of the same damn conclusions are in there, worded a little differently.” Fiola said the Legislature responded to earlier investigations with money and technology, and she wants to know what went wrong. “Was it five people who didn’t do their job? Is it a structural setup of the organization?” she asked.
Fiola said she is sickened by the case. “Nobody’s eyes were on the child, and the ones who were didn’t seem to do what they were supposed to be doing,” she said.