Starved and Forgotten: The Death of David Almond and DCF’s Systemic Failures

Fourteen-year-old David Almond died on October 21, 2020, emaciated and battered on a filthy floor in Fall River, Massachusetts. Responding paramedics found the autistic teen barely breathing, starved, beaten, and covered in feces. In the next room sat his father, John Almond, and the father’s girlfriend, Jaclyn Coleman, the very people entrusted by the state to care for him. Just months earlier, Massachusetts’s Department of Children and Families (DCF) had returned David and one of his triplet brothers to this household despite a long history of abuse and neglect by John Almond. It was a fatal decision. “David Almond was living with autism and doing well when the state returned him to his abusive parent. Within months, the 14-year-old was dead,” one investigation reported bluntly.

David’s death sent shockwaves through the community and prompted a scathing inquiry into how the system enabled such a tragedy. “It’s very clear from reading that report that David Almond’s death was preventable,” Massachusetts Governor Charlie Baker said after the investigation. Indeed, David’s case reads like a checklist of systemic failures. Years before, David and his brothers had been removed from their parents for abuse and neglect. The boys thrived in a congregate care program, where staff affectionately called David the “mayor” of his special education school. Yet in early 2020, DCF inexplicably chose to give their father another chance and returned two of the vulnerable triplets to the very environment from which they had been rescued. This reunification happened without any meaningful evidence that John Almond had changed. In fact, a little over a year earlier a Juvenile Court judge had deemed Almond unfit to care for the triplets and kept the children in DCF custody. DCF’s own internal records show that by July 2019, the agency abruptly reversed course, switching the goal from adoption to reunification, even one day after that court ruling against the father’s fitness. According to the Office of the Child Advocate (OCA), DCF Fall River managers pushed to reunify the family despite the parents’ minimal participation in required services and without assessing any actual improvement in their parenting abilities. No one, not DCF, not the juvenile court, not any attorney involved, insisted on a careful reunification plan or proof that the home was safe. They sent David and his brother back to a cramped one-bedroom apartment already teeming with seven people. “The apartment was not big enough for four children and three adults. Nobody would have allowed it, let alone what was happening in there,” David’s grandfather Boy Dawes recalled.

On March 13, 2020, DCF social workers delivered David and his brother Michael back to their father’s door. Three days later, COVID-19 lockdowns began. What followed was a disastrous dereliction of duty masked by pandemic precautions. In-person home visits were halted and DCF failed to classify the Almond family as high-risk, which would have required face-to-face safety checks despite COVID. Instead, for seven months, no official laid eyes on David. Social workers “visited” only via brief Zoom calls, during which Mr. Almond and Ms. Coleman often manipulated the situation, not allowing the boys to speak freely or at all. The parents prevented David and Michael from attending any in-person or even remote schooling, cutting off a critical lifeline that might have raised alarms. Fall River Public Schools admit that neither boy received any education or services from the day they left the group home to the day David died. Teachers and service providers could not reach the children, home visits from therapists stopped. DCF missed glaring warning signs. During one video check-in, workers noticed a visible wound on David’s face, but Ms. Coleman waved it off as self-inflicted, and they accepted that. “Mr. Almond and Ms. Coleman continuously circumvented contact with DCF staff, the Fall River Public Schools, and other providers,” the OCA report found, noting that DCF never adequately assessed how the pandemic was enabling this dangerous isolation. By the time a worried provider or teacher might push the alarm, it was already too late.

When first responders finally arrived on that awful October day, they found a child who had literally been tortured and deprived to death under DCF’s watch. David weighed under 80 pounds. His surviving brother Michael, also autistic, was found alive but severely malnourished and hospitalized for months. The appalling details of abuse, starvation, beatings, confinement in excrement, immediately raised a fundamental question: How could this happen while a family was supposedly under DCF supervision? Fall River police charged John Almond and Jaclyn Coleman with second-degree murder and child endangerment. Both have since pleaded guilty. But the family and public refused to let the blame stop with the individual abusers. “Linda and Boy Dawes point the finger at DCF for reuniting the boys with their father who had a long-documented history of abuse and neglect,” one report stated. The Dawes, David’s grandparents, had cared for the triplets in the past and were desperate to keep them safe. They say DCF shut them out of the reunification decision entirely. “They never contacted us, and if they would have, this would not have happened. We had no rights,” Boy Dawes said bitterly. After David’s death, the grandparents expected to take in the surviving boys, but DCF instead kept custody and even separated the brothers into different group homes. To this day, Boy and Linda Dawes say no one at DCF has ever apologized for the fatal mistake. “You’re responsible for this. At least say you’re sorry. Look us in the eye and say you know you screwed up. Nobody’s done that,” Boy said.

The tragedy of David Almond is not just a story of one bad parent, but a story of institutional failure at every level. The Massachusetts Office of the Child Advocate, an independent oversight agency, released a 107-page investigative report in March 2021 that reveals multiple missed opportunities to save David. The OCA concluded unequivocally that DCF’s Fall River area office made a grave error in reunifying the Almond boys with their father. “The DCF area office decision to return the boys home was not clinically justified and failed to address the children’s special needs and safety,” the report found. In other words, DCF managers based their decision on optimistic hopes and box-checking exercises rather than hard evidence that the father was ready and able to care for two autistic teenagers. An internal DCF review later admitted the case worker unit had never performed a proper risk assessment or developed a holistic formulation of the family’s problems. They did not grasp John Almond’s severe substance abuse issues or his pattern of violence and neglect, the very issues that had led to multiple prior removals of the children. Crucially, the agency showed a profound ignorance regarding David’s disabilities. David and his brothers had significant developmental needs, yet DCF provided no specialized support or expertise for handling such children. The OCA found that DCF had no training curriculum about individuals with disabilities and that the Fall River staff did not understand Autism Spectrum Disorder or the individual needs of the triplets. This lack of basic competence meant social workers failed to appreciate how vulnerable the boys truly were. Children with disabilities are more than three times as likely to be abused or neglected as their non-disabled peers, and far more likely to be seriously harmed by that abuse. Yet Massachusetts’ child protection system lacked both general knowledge and specific awareness of how David’s autism manifested, causing officials to overlook clear risk factors and warning signs leading up to his death.

The pandemic only exposed and amplified these underlying failures. While the world went into lockdown in 2020, DCF used the health emergency as cover for dangerous lapses in procedure. The agency had instituted a policy to require in-person visits for high-risk cases even during COVID, but they never categorized David’s family as high-risk. DCF’s pandemic risk criteria did not even include a child’s disability as a factor, nor did it flag families with extensive abuse histories like the Almonds as automatically high priority. As a result, David and his brother were never once seen in the flesh by a social worker from the day they went home in March 2020 until the day David died. All check-ins were virtual, easily dodged by the deceitful caregivers. No one from DCF pressed pause on the reunification, even as the agency lost contact with the boys. The OCA report scathingly noted that DCF staff missed many warning signs that David and Michael were in distress, from their absence at school, to their isolation from providers, to the obvious injury on David’s face. Any one of these red flags should have triggered an immediate in-person safety check. Instead, DCF officials took Ms. Coleman at her word and carried on with cursory monthly video calls while the boys wasted away out of sight.

Other institutions that were supposed to safeguard David failed him as well. The juvenile court overseeing the family’s case largely rubber-stamped DCF’s reunification plan without demanding a detailed transition strategy or proof of parental fitness. Court records indicate that the judge returned legal custody of David and Michael to their father in July 2020 in a perfunctory hearing that John Almond did not even bother to attend. The children’s court-appointed attorney, tasked with representing the boys’ best interests, raised no objection to sending two special-needs kids to live with a father who had barely spent time with them and a girlfriend who had no legal tie to them. Meanwhile, the Fall River Public School system never sounded an alarm as David and Michael vanished from class rolls. In part, the chaos of pandemic-era remote learning made it easier for them to slip through the cracks. Yet the OCA found FRPS failed to provide them any academic instruction or related services for seven months. Teachers later said they assumed DCF and the courts were monitoring the situation, not realizing that no one was actually checking on the boys. In reality, every agency assumed someone else was looking out for David, and thus no one did. Maria Mossaides, the Massachusetts Child Advocate, summed it up: “While there are only two people ultimately responsible for David’s murder, the OCA has determined that there was a multi-system failure, complicated by the pandemic, and that the safeguards that we expected to be in place, especially in DCF, turned out to be inadequate.” In short, the very safety net meant to protect David was riddled with holes, holes created by poor communication, lack of training, and sheer negligence.

DCF’s Commissioner, Linda Spears, acknowledged her agency’s disgrace in unusually frank terms. “It is clear to me that the safety net failed this child and failed this child in a significant way,” Spears said, announcing the firing of two Fall River DCF managers after David’s death. Governor Baker called the OCA’s findings “hugely distressing” and demanded that every recommended reform be implemented statewide as fast as possible. Among those recommendations were an overhaul of DCF’s reunification process to require rigorous safety assessments and proof of parental capacity before sending children home, better training and policies on handling cases involving children with disabilities, stronger collaboration with schools to monitor at-risk kids’ attendance, and a more active role for courts in scrutinizing any plan to return children to previously abusive caregivers. “We need to strengthen our systems so that the missteps that occurred in this case are never repeated,” Mossaides said, urging permanent changes to honor David’s memory.

As horrific as David Almond’s story is, it is not an aberration. Instead, it shines a light on a broader pattern of dysfunction in child protective services in Massachusetts and across the United States, where time and again bureaucratic failures and poor judgment have left children in lethal danger. “Tragically, this was not the first time we had seen a child die while under the supervision of DCF,” noted one Massachusetts lawmaker a year after David’s death. In fact, Massachusetts DCF has been rocked by one high-profile child welfare scandal after another over the past decade, each exposing familiar flaws: ignored warnings, lack of accountability, and a propensity to prioritize family preservation over child safety at all costs.

In late 2013, five-year-old Jeremiah Oliver disappeared from his Fitchburg home, after DCF social workers failed to check on him for months. The boy’s body was later found in a suitcase by the side of a highway. The public outrage over Jeremiah’s case was so intense that it forced the resignation of the state DCF commissioner at the time. An investigation revealed that DCF staff had simply not been doing their jobs. Home visits were skipped, red flags in the Oliver family’s file were overlooked, and supervisors failed to act as the child slipped through the cracks. The Office of the Child Advocate’s report on Jeremiah’s case concluded that while DCF’s chronic high caseloads and staffing shortages provided context, they were not an explanation or excuse for the repeated failures of those responsible. In other words, the tragedy was completely preventable, had the agency followed its own policies and put Jeremiah’s safety first. The fallout prompted some reforms, yet clearly the lessons were not fully learned. DCF promised to improve training and supervision after Jeremiah Oliver’s death, but less than seven years later, David Almond suffered a fate disturbingly similar in its systemic negligence.

Another notorious case is that of Harmony Montgomery, a little girl who at this moment remains missing and presumed dead. Harmony’s ordeal began in Massachusetts and ended in neighboring New Hampshire, but the failures of Massachusetts DCF and courts loom large. Born in 2014, Harmony spent her early years in foster care due to her mother’s instability and father’s incarceration. Shockingly, in February 2019, Massachusetts’s Juvenile Court awarded custody of four-year-old Harmony to her father, Adam Montgomery, a man with a violent criminal history who had never raised her. Just months after being handed over, Harmony vanished. It was not until late 2021 that authorities in New Hampshire discovered she was missing and later charged Adam Montgomery in connection with her disappearance. Massachusetts’ Child Advocate launched an investigation and found the exact same fundamental error as in David’s case. “Harmony’s individual needs, wellbeing, and safety were not prioritized or considered by any state entity,” the OCA report concluded. Officials were so focused on asserting the parents’ rights and closing the case that they failed to account for the child’s welfare. DCF never even completed a full assessment of Adam Montgomery or investigated his capacity to care for Harmony, yet the agency did not oppose transferring the little girl to him. Neither the judge nor Harmony’s own attorney ensured that Harmony’s best interests were front and center. There was no plan to transition her safely to her father, no verification of his home situation in New Hampshire, and no follow-up by Massachusetts once she left the state. As Maria Mossaides starkly put it, the system put parents’ rights above a child’s life, with devastating results. Harmony’s case highlights how interstate and inter-agency gaps can form a deadly blind spot. Massachusetts DCF effectively washed its hands of responsibility once a judge gave custody to the father, despite the fact that no child welfare agency in New Hampshire was officially supervising the placement. The ripple effect of miscalculations in Harmony’s case, from DCF to lawyers to the court, echoes the same misjudgments that killed David Almond. As one observer summed up, “When children are not at the center of every aspect of the child protection system, then the system cannot truly protect them.” Harmony was not at the center, and she paid the price.

Massachusetts DCF’s shortcomings do not only arise in reunification scenarios. They extend to the agency’s oversight of children in foster care, where DCF is directly responsible for a child’s well-being. Astonishingly, even under its own roof, DCF has allowed abuse to fester. A chilling example came to light in the so-called House of Horrors foster home in Oxford, Massachusetts. For years in the 1990s and 2000s, DCF placed child after child with a foster couple named Susan and Raymond Blouin despite a mounting pile of reports that these foster children were being savagely abused. It was not until investigative journalists dug into the situation that the truth emerged. Children in the Blouin home were locked in dog cages, submerged in ice baths, forced into sexual acts, and threatened with death if they told. At least fourteen separate reports alerted DCF to potential abuse in that foster home, and the agency ignored them. Multiple children’s lives were irreparably scarred as a result. In 2023, four survivors of the Blouin house of horrors finally won a seven million dollar legal settlement from the state, a rare moment of justice and acknowledgment of DCF’s culpability. “DCF was created to protect kids like me. It turned out DCF did just the opposite. It is an agency desperately in need of reform,” said John Williams, one of the former foster children, upon announcing the settlement. His words resonate far beyond that single case. From children starved in reunified homes to children tortured in foster placements, a damning pattern emerges. The very agency charged with safeguarding the most vulnerable has repeatedly enabled their abuse instead.

In the wake of David Almond’s death, Massachusetts officials expressed outrage and sorrow, as they always do after such scandals. There were press conferences and promises, new trainings, policy reviews, even personnel firings at the local DCF office. But for families and advocates who have seen this all before, words are not enough. “At least say you’re sorry. We know DCF screwed up,” pleaded David’s grandfather, anger mingling with grief. That apology never came. Instead, the agency clammed up behind “state and federal privacy” excuses and generic statements. When pressed by reporters, DCF refused to discuss the Almond case, citing confidentiality, the same refrain it offers every time a child dies on its watch. In a statement, DCF said it “is dedicated to safely reunifying families” and is “fully committed to implementing the reunification tool,” referring to a new risk assessment checklist it supposedly began developing after David’s death. Tellingly, the department admitted it was nearly two years behind in rolling out these safety reforms meant to prevent another tragedy. For the Dawes family and many observers, this slow pace and bureaucratic jargon feel like more evasion of true accountability. Where was that urgency when David was wasting away in 2020? Why did it require a child’s death, yet again, for DCF to recognize glaring flaws in its practices?

Massachusetts is not alone in these systemic shortcomings. Child protection agencies nationwide have too often favored family reunification or preservation at the expense of a child’s wellbeing, a tilt that critics say stems from laudable intentions gone awry and under-resourced systems overwhelmed by caseloads. But the bottom line is that children like David, Harmony, and Jeremiah are dead because the systems meant to shield them did not do so. Each case follows a heartbreakingly similar script: warnings ignored, bureaucracy prioritized over basics, and no one held accountable until it is far too late. After Jeremiah Oliver’s death, DCF leaders promised a fresh start for the agency. After David Almond’s death, they again pledged to do better and implement recommendations. Yet here we are, cycling through tragedy after tragedy.

It is clear that DCF’s culture must change, and that change must be enforced through transparency and outside pressure, not just left to internal fixes. When frontline social workers miss visit after visit or dismiss obvious signs of abuse, there have to be consequences beyond a stern memo or retraining. When managers push children out of safe placements into treacherous ones to hit reunification goals or clear their caseload, that cannot be brushed off as a communication breakdown. The Massachusetts child welfare system has evaded true accountability for too long, shielded by confidentiality laws and a lack of public scrutiny until a horror makes headlines. Advocates argue that nothing short of an overhaul, in training, in oversight, and perhaps in leadership, will suffice. “Based on our review it was clear that MA DCF was an agency in crisis that could not ensure the safety and welfare of the children in its care,” concludes a report by one child advocacy group. The evidence certainly bears that out.

Little comfort that is to the memory of David Almond. He was a boy who loved SpongeBob cartoons and playing Mario games with his brothers. He should have been safe in state custody, where he was thriving, but instead DCF handed him back to the people who would starve and beat him to death. “David’s death was preventable,” Governor Baker said, a harsh indictment of the system that failed this child. Preventable means it did not have to happen. David should be alive, Harmony Montgomery should be starting third grade, Jeremiah Oliver should be a teenager with memories of a loving childhood. Instead, we have graves and empty homes, and officials scrambling to explain why. The true measure of justice for David and all these children will be whether the system that so egregiously betrayed them finally changes its ways. “We have the opportunity to honor his memory by making permanent changes that will protect other children,” Child Advocate Mossaides urged. Those changes are desperately needed. Until they happen, until DCF and its counterparts nationwide prove that they will put child safety above all else, every vulnerable child remains at risk of becoming the next David Almond, a name added to the litany of shame.