She Was Already Dying When DCF Walked Away: How Massachusetts Abandoned A’zella Ortiz And Pretended It Could Not See
On the night of October 14, 2024, a 911 dispatcher in Worcester took a call that should haunt this state forever. A four year old girl, A’zella Ortiz, was not breathing. The caller said she had “fallen on the floor” in a third floor apartment at 11 Sever Street. When first responders climbed the stairs and pushed into that unit, they found a dying child who looked nothing like a routine fall victim. She was rail thin. She was covered in bruises. Her tiny body told a story of starvation and violence that had been playing out for years while Massachusetts officials checked boxes and closed files. Her six year old sister and two year old brother were there too, just as broken, skeletal from malnutrition, dehydrated, injured, and terrified. The apartment around them reeked of filth and addiction, littered with drug paraphernalia and an unsecured gun within reach of the children.
At the hospital, doctors fought to keep A’zella alive and failed. In the early hours of October 15, she was pronounced dead. The medical examiner later ruled her death a homicide, caused by multiple blunt force injuries. Her father told investigators she had fallen from a kitchen table. Physicians compared the fracture in her skull to the force of a fall from two stories up and said the explanation made no medical sense. Her two year old brother had his own skull fracture. Her six year old sister had rotting teeth, bruises, profound developmental delays, and fentanyl in her bloodstream. These were not children who had just “fallen.” These were children who had been living in conditions so abusive and neglectful that their bodies were shutting down.
This horror did not happen in isolation. It unfolded in a household the Massachusetts Department of Children and Families knew inside and out. DCF had an open “intact family” case on A’zella’s family from 2018 to 2019, then again from 2020 until October 4, 2023. Over nearly four years of active supervision, DCF documented supported neglect, escalating risk, missed medical care, and serious developmental concerns. The agency completed at least thirty six home visits, wrote six separate family action plans, and watched the risk rating on its own Structured Decision Making tool climb from low, to moderate, to very high. Yet the basic facts never changed. The children stayed hungry, unseen, and untreated. In October 2023, DCF closed the case while believing, incorrectly, that the family had moved out of state. At the moment the file was shut, no worker had physically laid eyes on any of the children for 114 days. Less than a year later, A’zella was dead on a hospital gurney.
The story starts in 2018, before A’zella was even born. Her older sister, “Luna,” arrived in October of that year, substance exposed to marijuana. DCF opened a neglect case, investigated, and substantiated concerns. Both parents admitted using marijuana. The agency watched them for about eight months and then walked away, declaring the risk reduced enough to close. There was no indication that the underlying issues of substance use, isolation, and instability had truly been resolved. The state simply decided it had seen enough.
In 2020, history repeated itself. A’zella was born, also substance exposed. A new neglect report came in. Police had already been called to the home for loud arguments. DCF again substantiated neglect, now involving two children. The risk level formally ticked up to “moderate.” Caseworkers created an action plan that was supposed to change everything. Get the kids to the doctor. Get Early Intervention evaluations for speech and developmental delays. Meet with DCF every month. On paper it looked like a plan. In real life almost nothing happened. The parents skipped appointments, ignored referrals, and kept the children almost entirely confined inside the apartment. Luna, approaching three years old, still did not speak. A’zella’s care lagged. The parents’ drug use continued. DCF continued to visit, to document, and to hope that gentle nudging would fix what was clearly not getting fixed.
Inside the agency, there were already alarm bells. In June 2021, DCF did an internal quality review on the case. Staff flagged the same concerns that would ultimately show up in A’zella’s autopsy photos. Parents staying in bed late while babies cried. A home that was dirty and chaotic. Police responses to domestic disputes. A three year old child who was completely nonverbal and had never been evaluated. Both children missing basic pediatric care. But after recognizing that the case was high risk and stagnant, DCF did what it would do over and over again. It wrote down the concerns, scheduled more visits, and chose not to escalate.
Then the outside world tried to intervene, and DCF slammed the door. In late December 2021 a neighbor or other non mandated reporter called DCF to say that the children were frequently heard crying while no adult responded, that the apartment smelled like marijuana, and that the parents were often sleeping and inattentive. It was a textbook report of chronic neglect. DCF never investigated it. Intake “screened out” the report after the father assured the social worker he did not sleep while the kids were awake. The Office of the Child Advocate would later call that decision a clear violation of DCF’s own Protective Intake Policy, which forbids screening out serious neglect reports based solely on an unverified self serving denial by the accused parent. One phone call from the father overrode the voice of a witness and the agency’s own knowledge of how this family lived.
By 2022 the situation was deteriorating in plain sight. The mother drifted in and out of the home. The father became the primary caregiver, overwhelmed and resistant to help. He refused a parent aide. He declined childcare. He did not follow through on medical or developmental appointments. The children stayed isolated in a small, messy apartment, almost never seen by anyone but their parents and the DCF worker. The agency convened a management meeting to discuss the escalating risk. Supervisors recommended contacting relatives, getting a substance use specialist involved, clarifying who was actually caring for the children. Some of those steps happened. Many did not. What never happened was the one step that could have saved these children: going to court and telling a judge that this family had failed every voluntary plan thrown at it.
In October 2022, the danger spiked. The mother gave birth to a third child, a baby boy called “Mateo” in the reports. He, too, was born substance exposed. When DCF dug into medical records, the picture that emerged was devastating. Four year old Luna had not been seen by a doctor in nineteen months. She had significant speech delays and had missed repeated referrals to specialists. Two year old A’zella had missed or cancelled eighteen appointments in a little over a year, had serious dental issues, and was not speaking. The pediatrician’s concerns for both girls were detailed and urgent. DCF’s own risk tool, finally updated, rated the family “very high risk,” the highest category the system has.
Faced with this, DCF met with its lawyers, weighed its options, and backed down again. Instead of seeking custody, the agency crafted a safety plan that allowed the mother to take newborn Mateo home while declaring her too unsafe to be alone with Luna and A’zella. She was barred from unsupervised contact with the older children but permitted to parent the infant who needed around the clock care. The contradictions were never explained in the record. The plan relied on the same father who had already failed to get his kids medical care, who continued to use marijuana, and who resisted outside help. When the parents ignored or violated the conditions, DCF noted the breaches and kept going as if a signed piece of paper could substitute for actual safety.
By early 2023, the case file read like a loop. The parents promised to seek evaluations for Luna’s delays and did not. They said they would enroll the kids in childcare and did not. They reported ongoing marijuana use but insisted there was always a “sober caregiver,” a fiction no one could verify because almost no one else ever saw the children. DCF workers kept visiting monthly. The risk rating stayed at very high. In January 2023, staff even floated the idea of a legal consultation to consider filing a Care and Protection petition. According to the Child Advocate, there is no evidence that consultation ever happened. The idea vanished, replaced by more of the same: another month, another visit, another unfulfilled plan.
Then came July 2023, the month DCF effectively chose to lose these children. First, the pediatrician told the DCF worker that nine month old Mateo was badly overdue for appointments. That same day, the mother texted that the family was “in New York” visiting relatives but would be back soon. Shortly afterward, another 51A report hit the intake unit. This one described a scene that should chill anyone who has ever worked in child protection. Parents failing to pay rent and facing eviction. Adults passing out while high, leaving children alone for hours. Little kids left sitting in their own feces and urine. Mattresses soaked in urine, feces smeared on the floor. The kind of horror people imagine when they say “the system should step in before it is too late.” DCF did not step in. Intake screened out this report too, on the grounds that the family “no longer lived” at the address. The only basis for that belief was the mother’s unverified claim that they were in New York. The Child Advocate later called this decision another clear violation of policy. A report describing a house of filth and unconscious caregivers was dismissed because the alleged abusers said, essentially, “we moved.”
Over the next two months, DCF lost what little contact remained. Workers could not reach the parents. Police checked old addresses. Relatives were contacted. Finally, the mother answered a call and repeated that they were staying with her mother in New York. When DCF asked for an address to alert New York child welfare officials, she did not provide one. Caseworkers believed they did not have that address anywhere in their records. In fact, DCF already had the maternal grandmother’s full New York address, including apartment number, from earlier family search documentation. It had been entered once and then forgotten, buried in a system so disorganized that its own staff could not find the information they needed to keep children alive.
In September, Massachusetts DCF tried to report its concerns to New York anyway, but with incomplete information. New York child protective services responded that they could not open a case without a verified address. At that point, no one in Massachusetts knew where the children were. No one had seen them since June. No one had spoken to them on the phone or through a video call. Risk was sky high. Instead of seeking a court order, a warrant, or law enforcement assistance to locate them, DCF chose the cheapest option the system offers. It closed the file. On October 4, 2023, DCF officially ended its case, citing the family’s presumed move out of state, even though the agency had not laid eyes on any of the three children for 114 days.
The truth is that the family came back almost immediately. Within two or three weeks of leaving, they returned to Worcester and moved into Sever Square. There were no more DCF visits, no pediatric appointments, no school enrollment for the six year old. For nearly a year the children disappeared into the shadows of that third floor apartment, slowly starving in a home steeped in drugs and violence while Massachusetts comforted itself with the story that they were someone else’s problem in another state.
When A’zella died and the full horror finally broke into public view, DCF’s leadership expressed sorrow and promised to review policies. The Worcester County District Attorney charged her father, Francisco Ortiz, with murder, multiple counts of permitting substantial bodily injury to a child, reckless endangerment, and improper firearm storage. He has pleaded not guilty and sits in jail awaiting trial. The Office of the Child Advocate launched an investigation of the state’s role and, in December 2025, released a report that should end any illusion that this was a one off tragedy. The OCA described the neglect these children endured as “chronic and cumulative” and concluded that DCF failed to develop a strong clinical understanding of the family, misused its own risk tools, and missed repeated opportunities to intervene. The report is explicit: what happened to A’zella was not a bolt from the blue. It was the foreseeable endpoint of a system that treats chronic neglect as background noise until a body hits the slab.
This is not the first time Massachusetts has heard this story. Before A’zella there was Bella Bond, the little girl pulled from Boston Harbor, whose family had long histories with DCF. There was David Almond in Fall River, a fifteen year old autistic boy who died of starvation in 2020 while on an “intact family” case eerily similar in structure to A’zella’s. There was Harmony Montgomery, the New Hampshire child with Massachusetts roots whose disappearance exposed cross border failures and blind spots. In each case, oversight reports cataloged missed warning signs, neglected risk assessments, premature case closure, and the quiet decision to trust parents’ words over the evidence in front of workers’ eyes. The OCA itself has said that A’zella’s case is “not isolated” but indicative of deeper practice and policy gaps in how DCF manages in home cases.
What these reports describe is more than a series of mistakes. They reveal a culture inside DCF that prioritizes avoiding conflict with adults over protecting children who have no voice. Workers did visit regularly. They filled out forms. They wrote action plans. They consulted specialists. In a bureaucratic sense, they did a lot. But when the risk indicators screamed red, when children remained nonverbal and unseen, when neighbors described conditions that would make any parent sick to read, the system refused to cross the line from “support” to “protection.” The risk tool labeled this family very high risk; leadership chose to treat it as just another troubled household that might get better if everyone stayed polite and hopeful. That is not child protection. That is reputation management with kids’ lives as collateral.
If you are reading this and thinking “this could have been prevented,” you are right. If you are telling yourself “but DCF is overwhelmed and underfunded,” remember that every single decision that mattered in this case cost nothing but courage. It costs nothing to refuse to screen out a serious neglect report based on a parent’s denial. It costs nothing to insist that a child be physically seen before a case is closed. It costs nothing to tell a judge the truth about a family that has blown off six action plans and dozens of medical referrals. The price of not doing those things was paid by a four year old girl whose name should be known in every hearing room on Beacon Hill.
A’zella Ortiz should be starting school, learning to read, laughing with classmates at recess. Instead, her name is attached to an autopsy and an indictment. Her sister and brother will grow up carrying scars that doctors and therapists can see and others they cannot. The people and institutions who were supposed to stand between them and catastrophe are issuing press releases and promising incremental reforms. That is not enough. Not for this child. Not for any child still trapped in a filthy apartment today while their case file quietly drifts toward closure.
Massachusetts does not need more platitudes. It needs hard lines written into law and enforced without apology. Do not close an in home case when a child has not been physically seen in more than thirty days. Do not allow intake to screen out serious neglect reports on the word of the alleged abuser. Treat “chronic and cumulative” neglect as the emergency it is, not as a sad but acceptable baseline. Give the Office of the Child Advocate the power to demand, not just recommend, changes when patterns like the ones in this case appear. Make every leader inside DCF acknowledge, on the record, that intact family cases are where some of the worst harm happens and that “family preservation” without real safety is just a slogan that buries children.
A’zella’s story is not comfortable. It should not be. It is a mirror held up to a state that keeps telling itself it cares about children while designing a system that lets kids vanish the moment a parent claims to have crossed a state line. The people who failed her will insist that no one could have predicted exactly what night the 911 call would come. They did not need to predict the date. They only had to believe what they were already seeing.
Remember her name. Say it when you read the next oversight report and the next hollow promise of reform. Say it when someone tells you DCF is “doing the best it can.” A system that closes a very high risk case after months of missed contact, without once laying eyes on the children it is paid to protect, is not doing its best. It is choosing not to know. It is choosing not to act. And as long as that choice remains acceptable, there will be more children like A’zella Ortiz whose lives end in the dark, unheard, unseen, and officially “closed.”
