Office of the Child Advocate sights DCF oversights after Massachusetts man charged in death of 4-year-old daughter

BOSTON, MA – The Office of the Child Advocate released findings and recommendations on Wednesday following an investigation into the death of A’zella Ortiz and the serious bodily injury of her two siblings.

A’zella died on October 15, 2024. A’zella’s father, Francisco Ortiz, has been charged with her murder and is currently in jail awaiting trial. According to OCA, the Department of Children and Families had closed a case with this family one year prior and was not involved with the family at the time of A’zella’s death.

“Previously, DCF served this family between 2018 and 2023 for a total of three years and eight months due to supported findings of neglect of A’zella and her two siblings by their parents.

“In accordance with state law, the Office of the Child Advocate is authorized to investigate the actions and inactions of state agencies following any serious injury or death to a child who is receiving state services. The OCA decided to publicly release this report because it exemplifies concerns regarding DCF’s risk assessment and case management practices that the OCA has raised before, both in previously released investigation reports and on an ongoing basis with DCF through the OCA’s ongoing oversight work.

“The vast majority of children served by DCF are living at home, with their families. Our goal as a Commonwealth should be to ensure that these children can stay home – safely. For that to happen, state intervention with families where maltreatment has occurred must be child-centered, based on an accurate assessment of risk, time-limited, and serve to support and stabilize the family. Unfortunately, that is not what happened in this case, with tragic results for A’zella and her siblings,” said Maria Mossaides, Director of the Office of the Child Advocate. “The OCA issues our findings and recommendations today with the hope that they will spur action to improve the way our state serves the children who make up the vast majority of DCF’s caseload – children living at home.”

“Most families receiving DCF services (78% in FY25) are “intact families,” meaning that the child has not been removed from the home.

Key Findings & Case Details

“The OCA found that DCF did not have a comprehensive understanding of the dynamics and needs of the family (“clinical formulation”), leading to an improper assessment of the risks to the children. As a result, warning signs were missed, and necessary interventions did not occur.

“The OCA found that the DCF case management team’s approach to the family did not change over the course of three years, even though there was no improvement in the family’s functioning or the children’s care and the risk to the children increased.

‘”As a result, A’zella and her siblings experienced neglect in the care of their parents that was chronic and cumulative – including inadequate supervision, parental substance use, and failure to obtain pediatric medical care, particularly specialist care for two of the children who were nonverbal. This resulted in numerous missed health care appointments, failure to address developmental delays, poor nutrition, social isolation, and a situation that, after DCF closed its case, escalated into life-threatening harm.

“The DCF case management team closed the case believing the family had moved to New York, information that was later determined to be inaccurate. At the time the DCF case closed, it had been 114 days since the DCF case management team had last seen the children. A’zella’s death followed approximately one year after the case had closed.
 
“The OCA finds that although the escalation of the situation after DCF closed the case was rare and may not have been foreseeable, DCF’s intervention with the family over the course of three years provided no measurable improvement to the safety of the children.

“Further details about the specifics of the case can be found in the report.

Key Recommendations

“The OCA believes the issues observed in this case are not isolated, but instead are indicative of broader DCF policy and practice gaps that require focused attention and improvement in two key areas:

0. “Ongoing and accurate assessment of risk, particularly in the context of neglect and intact families.
   
1. ‘The establishment of a structured quality assurance framework to guide DCF’s work with intact families. For children placed in state custody, DCF currently has a highly structured quality assurance framework with clear policies and monitoring practices, including a variety of mandatory independent reviews. These cases also receive oversight from the Juvenile Court. A similar system does not currently exist when DCF works with intact families.
   

“OCA recommendations to DCF include:

• “Revise and update the DCF Case Closing Policy to provide greater clarity and guidance, with a particular focus on scenarios where a family has prolonged DCF involvement and/or their whereabouts are unknown.
  
• “Establish a structured quality assurance framework to guide DCF casework with intact families that is well-researched, well-resourced, and multifaceted.
  
• “Develop and implement a stand-alone policy about case consultations with the already existing DCF clinical specialists that includes procedures to make sure the recommendations are addressed.
  

• “Strengthen the definition of “clinical formulation,” to ensure that it is child-centered and guides assessment, casework, and decision-making.
  
• “Create and embed an understanding of chronic neglect into DCF casework, recognizing that chronic neglect is a subset of neglect with its own unique characteristics and risks.

• “Conduct a training needs-assessment of the DCF workforce to systematically identify the knowledge, skills, and capacity gaps with a particular focus on clinical formulation, child development and growth, parental engagement, substance use, and neglect.”
  

“This report asks that we, as a Commonwealth, consider seriously the investment needed to support and stabilize families so that children can truly thrive,” said Director Mossaides. “We are asking that the DCF administration step back and consider the big picture of how the Commonwealth engages with intact families, how the agency measures risk with only limited knowledge, and how to evaluate the cumulative effect of chronic neglect. As DCF engages in that work, it deserves and requires the support of the Commonwealth so that we can truly honor and serve our children.”

On October 14th, 2024, call came into Worcester dispatch for a report that a mother’s 4-year-old daughter was not breathing after falling on the floor with CPR in progress.

A’zella was transported to UMass Memorial Medical Center where she was pronounced dead.

According to NBC 10 Boston, doctors who treated the 4-year-old stated that she had a skull fracture consistent with falling two stories and that she had bruises all over her body. The father stated that the child fell from a kitchen table and the other bruises were from previous falls.

Two other children in Ortiz’s care appeared to be bruised, malnourished and dehydrated.

A GoFundMe fundraiser announced that four-year-old A’zella Sky Ortiz of Worcester had died unexpectedly.