Massachusetts DCF’s Tragic Failures and the National Crisis in Child Protection
The Massachusetts Department of Children and Families (DCF), the state’s child protective services agency, has become synonymous with failure and heartbreak. Over the past decade, Massachusetts has fallen into a nightmarish cycle: a child dies under DCF’s watch, public outrage erupts, officials promise reforms, yet before long another tragedy occurs. Despite being one of the nation’s wealthiest states, Massachusetts consistently ranks among the worst for child welfare outcomes. This is not an isolated problem. It reflects a greater crisis in child protective services across the country. Agencies charged with shielding vulnerable children from harm are too often the source of systemic negligence, leaving children in deadly situations or shuffling them through a life of chaos and trauma. The story of Massachusetts’ DCF is a damning case study in how child protection can go terribly wrong, and it echoes alarming failures nationwide.
A Cycle of Tragedy in Massachusetts
Time after time, Massachusetts children have suffered and died in horrifying circumstances that DCF knew about but failed to prevent. One of the most infamous cases was that of 5-year-old Jeremiah Oliver, who vanished from his home in Fitchburg in 2013. Jeremiah’s family had an open DCF case due to past abuse concerns, yet social workers lost contact for months. In April 2014, the little boy’s body was found stuffed in a suitcase off a highway. He had been murdered, and a subsequent investigation revealed that DCF staff had not made required home visits for at least seven months, essentially leaving this child to slip through the cracks. The scandal provoked public fury and led to the resignation of DCF’s commissioner at the time. It was painfully clear that the very agency meant to protect Jeremiah had instead abandoned him.
Tragically, Jeremiah’s case was not an outlier. In the years that followed, Massachusetts saw a series of dreadful incidents, each exposing familiar breakdowns at DCF. In mid-2015, police found 7-year-old Jack Loiselle in a coma, beaten and starved by his father in Hardwick. DCF had received numerous reports that Jack was being abused, but the agency failed to piece together the pattern. A DCF internal review later admitted that social workers treated each new abuse report in isolation and never grasped the full danger Jack was in. Governor Charlie Baker grimly noted that “no one had a complete understanding of the situation” until it was too late. That summer, another horror came: Avalena Conway-Coxon, a toddler just 2 years old, died while in a DCF-licensed foster home. It turned out the foster home should never have been approved at all. DCF staff had ignored their own policies during the licensing process and provided almost no oversight. Governor Baker acknowledged a “blatant lack of oversight” in Avalena’s death, underscoring that basic procedures designed to keep foster children safe were simply not followed.
Only weeks later, yet another child’s name made headlines: Bella Bond, age 2, better known as Boston’s “Baby Doe.” In summer 2015, her tiny body washed ashore on Deer Island after her mother’s boyfriend murdered her. Bella’s family had a long history with DCF, with multiple allegations of neglect and abuse, but DCF had closed her case not long before her death. A review by the Office of the Child Advocate found that DCF’s risk assessments were deeply flawed and that the agency prematurely terminated supervision in Bella’s home despite clear red flags about her mother’s ability to care for her. In case after case, critical warning signs were missed or ignored.
The pattern continued into recent years. In late 2019, a two-year-old girl named Lyric Farrell was returned from foster care to her mother’s custody in the town of Whitman, only to be found unresponsive a few weeks later with severe head trauma. Lyric, who had spent most of her life in foster care, died in the hospital. Authorities discovered bruises and signs of abuse that apparently accumulated in the short time after DCF reunified her with her mother. The decision to reunify, as with so many others, happened behind closed doors with little transparency or accountability. And in 2020, 14-year-old David Almond of Fall River, a boy with autism, was found dead of neglect and starvation just seven months after DCF sent him back to his father. David had weighed barely 80 pounds at death and endured squalid, brutal conditions while under “parental supervision” ostensibly deemed acceptable by the state. An investigative report later chronicled how social workers during the COVID-19 pandemic conducted only perfunctory check-ins, often by phone or video, and failed to see the obvious danger David was in. Like so many before him, this child was essentially abandoned by those duty-bound to protect him.
Each of these gut-wrenching stories prompted the same cycle: public shock and grief, officials scrambling to explain, and solemn vows that “we must do better.” Massachusetts lawmakers and governors commissioned investigations, audits, and expert panels. Press conferences were held, apologies given, and reforms announced repeatedly. Indeed, Massachusetts has been through wave after wave of child welfare reform efforts. After Jeremiah Oliver’s death, the state brought in the esteemed Child Welfare League of America to assess DCF in 2014. In early 2015, a legislative Post Audit and Oversight Committee issued a blistering report declaring that DCF was “an agency in crisis” that could not ensure children’s safety. Governor Baker, who took office in 2015 amid this turmoil, promised an “end-to-end” overhaul of DCF. New policies were rolled out: improved intake screening, lower caseload targets, better training, and re-hiring of more front-line social workers. The agency got new leadership and a bigger budget. There were additional overhauls in 2019 and again in 2021, each hailed by officials as a turning point for a troubled system.
Yet the promised change never truly arrived. Over more than a decade, through multiple high-profile tragedies and reform pledges, Massachusetts DCF has been unable to implement and sustain meaningful improvements. A candid DCF case review in late 2015 admitted as much: despite successive reform initiatives, the agency still lacked the “policy framework, operating rules, and executional follow-through” required to protect all the children in its care. In plain terms, DCF’s fundamental practices remained broken. Front-line social workers remained overburdened and under-supervised. Critical information kept falling through the cracks. Supervisors failed to enforce standards, and leadership failed to hold the system accountable beyond the crisis of the moment.
A System That Keeps Failing Children
The consequences of these failures are reflected in grim statistics. By many metrics, a child who enters Massachusetts’ child welfare system is at higher risk of poor outcomes than in almost any other state. Children in DCF custody in Massachusetts tend to stay in foster care far longer than the national average, drifting through temporary homes for years. They often endure a dizzying number of placements, being moved from foster home to foster home, or to group facilities, which inflicts additional trauma. Massachusetts has ranked at or near the bottom nationally for placement stability, meaning kids here experience more disruption and chaos while in state care. It is not uncommon for a Massachusetts foster youth to cycle through four, five, or even more different homes. Siblings are frequently separated, and too many children end up languishing in institutional group settings instead of with families. Even basic health and education measures show serious shortcomings. Internal data revealed that barely half of foster children received required medical check-ups on time, and high school graduation rates for youth in DCF care have hovered disastrously low, often barely half the rate of other students. All this in a state that prides itself on education and healthcare excellence.
This dismal performance persists despite repeated infusions of funding and reform efforts. Massachusetts boosted DCF’s budget by millions, increased staffing, and implemented new policies after each tragedy. Yet those changes have not translated into safer children. For example, even after the much-touted 2015 reforms, Massachusetts still did worse than most of the country on six of seven key federal child welfare metrics in the next federal assessment. The agency’s own annual reports have struggled to show real progress. The same systemic issues keep emerging in audits and reviews: unmanageable caseloads, high staff turnover and burnout, shoddy record-keeping, inconsistent risk assessments, and poor communication both within DCF and with other agencies such as schools, law enforcement, and medical providers. A 2017 audit by the state auditor found DCF failed to investigate many incidents of serious injury to children in its care and failed to report critical incidents to the child advocate and district attorneys as required. In other words, not only was DCF missing chances to save children, it was not even being honest about the scale of the problem.
Perhaps one of the most damning indictments came from outside investigators in 2020, when federal officials concluded that Massachusetts DCF had systematically discriminated against parents with disabilities. The U.S. Department of Justice found that DCF violated the Americans with Disabilities Act by wrongfully removing children from parents simply because the parent had a disability, with no individualized consideration or support. One case highlighted a mother with a mild intellectual disability who had her infant taken at birth. The mother had done nothing to harm her baby, but DCF assumed she could not parent due to her disability. Such blatant bias not only tramples parents’ rights, it also fails children by depriving them of loving homes without cause. DCF eventually reached a settlement agreeing to overhaul its practices toward disabled parents, but this episode revealed an agency culture too quick to remove children based on prejudice while too slow to act when children were in genuine danger. It illustrated how misconduct at DCF cuts both ways, sometimes leaving children in abusive homes, other times tearing apart safe families. In both scenarios, vulnerable kids suffer.
Another factor that perpetuates failure is the veil of secrecy around child welfare proceedings in Massachusetts. The state’s family courts and DCF records are largely confidential, purportedly to protect privacy. But this secrecy also means that when terrible decisions are made, the public may never find out until after a child is dead. Even then, critical records and court transcripts are often sealed. This was powerfully demonstrated in the case of Harmony Montgomery, a 5-year-old New Hampshire girl with Massachusetts ties who was murdered by her father after a Massachusetts court gave him custody despite his violent criminal past. Only once Harmony was reported missing, two years after she was last seen alive, did the public learn that Massachusetts authorities had handed her over to a dangerous parent. Why did a judge do so? What did DCF recommend in that custody hearing? The answers remain hidden in secret court files. Such lack of transparency breeds zero accountability. It took media lawsuits and even the state’s Supreme Judicial Court to begin prying open the records of Harmony’s case. Observers have rightly pointed out that Massachusetts’ extreme confidentiality rules allow dysfunction to fester away from public scrutiny. Without sunlight, neither the press nor independent watchdogs can fully investigate DCF’s actions until it is far too late.
The cumulative picture inside Massachusetts is of a child protection system that repeatedly and predictably fails the very children it is supposed to save. From infants to teenagers, from cases of fatal abuse to cases of benign families wrongly separated, the Massachusetts DCF has caused or allowed immense harm. As one child advocate put it, children involved with DCF would almost be better off in any other state. It is a stunning indictment: Massachusetts’ most vulnerable children have been let down by an unaccountable bureaucracy, time and again.
Not Just Massachusetts: A National Crisis
As shocking as Massachusetts’ failures are, they are not unique. Child protective services agencies across the United States have a long history of systemic breakdowns, leading to countless preventable tragedies. The names and places differ, but the pattern is hauntingly similar: warning signs missed, bureaucratic inertia, children left in peril or tossed about by the system until something unspeakable happens.
In California, for example, the 2013 torture and murder of 8-year-old Gabriel Fernandez became a notorious symbol of a broken system. Gabriel was repeatedly beaten, burned, and starved by his mother and her boyfriend in Los Angeles County, all while the county’s Department of Children and Family Services had an open file on him. His teacher and others made multiple reports of severe abuse, Gabriel would come to school bruised and asking if getting hit was normal, yet social workers failed to intervene in time. After Gabriel’s death, an investigation revealed that workers had improperly closed earlier abuse referrals and failed to follow basic procedures that might have saved the boy’s life. The outrage was so great that Los Angeles prosecutors charged four social workers with felony child abuse and falsifying records in connection with Gabriel’s case, an unprecedented step, though those charges were later dismissed on appeal. The “Trials of Gabriel Fernandez” became the subject of a documentary, highlighting how an overburdened, mismanaged agency allowed a little boy to be tortured to death despite ample opportunities to rescue him.
In Illinois, 5-year-old AJ Freund suffered a similarly horrific fate in 2019. AJ was killed by his parents in a Chicago suburb after enduring years of abuse in a filthy, drug-ridden household. The Illinois Department of Children and Family Services had been alerted to problems in AJ’s home at least a dozen times. Police had found the house littered with feces and garbage. Doctors had reported suspicious injuries. Yet each time, the case was either closed or minimal actions were taken. After AJ’s body was found buried in a shallow grave, the public learned how egregiously the system had failed him. One caseworker even documented that the mother’s explanations for AJ’s bruises “made sense,” accepting obvious lies. The fallout led to several employees being fired and, remarkably, criminal convictions of two DCFS staff for their roles in negligently handling AJ’s case. It is exceedingly rare for child welfare workers to face criminal accountability, which speaks to how blatant the negligence was. The AJ Freund tragedy shook Illinois and underscored that the systems meant to shield children can become complicit in their abuse when basic protocols are ignored.
New York City faced its own reckoning after the 2016 death of Zymere Perkins, a 6-year-old boy in Harlem. Zymere died after his mother’s boyfriend beat him with a broomstick and left him to die, a final act of violence following months of beatings. The city’s Administration for Children’s Services had investigated at least five reports on Zymere’s family for suspected abuse or neglect in the years prior. A subsequent state review was scathing. It found many deficiencies in ACS’s handling of Zymere’s case, including superficial investigations, poor-quality interviews, and failure to follow up on obvious signs of danger. Caseworkers had chances to remove Zymere to safety but did not act decisively, in part due to lapses in supervision and a pattern of closing investigations without ensuring the child was safe. The Zymere Perkins case led to resignations in the city’s child welfare leadership and a package of reforms aimed at tightening oversight and retraining staff. But even those reforms were soon tested by further child deaths in New York, as officials struggled to break the cycle of reactive fixes that never seem to prevent the next tragedy.
Such stories abound from coast to coast. In Maine, a spate of child murders in 2021, including a 3-year-old beaten to death by her foster parent and a baby killed by his mother’s boyfriend, exposed serious flaws in that state’s CPS, eerily echoing the failures seen elsewhere. Florida’s system was rocked by the death of Nubia Barahona in 2011, an adopted 10-year-old girl found dead in her adoptive father’s truck after years of abuse, despite multiple warnings to Florida’s DCF that the Barahona children were in danger. In each case, investigations find that the information was there, concerned reports were made, but the agencies failed to connect the dots or act with urgency until it was too late. Children have literally died on CPS’s watch by the hundreds each year in America, many of them after authorities had already been notified of potential abuse. According to federal data, roughly 1,700 children die from abuse or neglect annually in the United States, and a significant portion of those families were previously known to child protective services. These are not just random, unforeseeable tragedies. They are systemic failures of government agencies that are supposed to protect children from exactly this fate.
Even when children survive, they can be profoundly harmed by CPS dysfunction. Foster care systems in many states inflict their own form of abuse via instability and neglect. Children taken into state custody often bounce between dozens of placements, have their belongings stuffed in trash bags as they move, miss out on schooling, and suffer trauma from the uncertainty. Nationally, foster youth are far more likely to become homeless, incarcerated, or victimized after leaving care, compared to their peers. These outcomes reflect systemic neglect on a grand scale. In Kansas and Missouri, an in-depth investigation by the Kansas City Star in 2019 called these children “throwaway kids,” highlighting how frequently they were failed by the very institutions charged with raising them. The series detailed heartbreaking stories of foster youth aging out into poverty, of children abused in foster homes or group homes, and of biological families needlessly separated by overzealous systems while truly endangered kids sometimes went unnoticed. The moniker “throwaway” is gut-wrenching but apt. It captures how CPS agencies have all too often treated these young lives as expendable.
It is no wonder that at least 15 states’ child welfare systems are currently under federal court oversight due to class-action lawsuits or settlements. From New Jersey to Oklahoma to Oregon, watchdog groups have sued states for violating foster children’s rights and putting them in harm’s way. One of the most damning judicial assessments came out of Texas, where a federal judge ruled in 2015 that the state’s foster care system was so deficient it violated children’s constitutional rights. In her scathing decision, U.S. District Judge Janis Jack wrote that the Texas system was essentially broken, with children almost uniformly leaving state custody more damaged than when they entered. She described a system where children were subjected to rampant maltreatment in foster homes, overmedication with psychotropic drugs, and a lack of safe, stable placements, a system that left vulnerable kids worse off, traumatized by the very intervention meant to save them. Years later, Texas is still struggling to meet the court’s mandates, illustrating how deeply entrenched these problems are.
A tragic common thread emerges when comparing these failures across states. Child protective services in America often react only after the damage is done, instead of preventing it. Agencies swing between extremes, at times accused of overzealous removals of children from families, and at other times blasted for leaving children in lethal situations in the name of family preservation. Front-line caseworkers tend to be young, underpaid, and burning out from untenable caseloads of complex cases. They operate within bureaucracies that are chronically under-resourced and mismanaged, where high turnover means constant loss of experience. Mistakes are made, warnings are missed, and children suffer. Political leaders usually only pay attention when a particularly awful case hits the news, leading to knee-jerk policy changes that rarely address the core issues. In short, the system built to shield children from harm too often perpetrates a different kind of harm, one of instability, indifference, and incompetence.
A Damning Call for Change
The ongoing failures of child protective services in Massachusetts and across the nation amount to a moral and societal crisis. Children, the most vulnerable members of society, are being failed by those who are sworn to protect them. These are not just headline-grabbing anomalies. They are the predictable result of systems that have not prioritized children’s safety, well-being, and stability. For every famous case like Gabriel Fernandez or Jeremiah Oliver, there are countless other children suffering in silence, their names unknown to us, bouncing between abusive homes and a neglectful bureaucracy until something snaps. We should not accept this as the status quo. Each of these children’s horrific stories should serve as a damning indictment and an urgent call to action.
Massachusetts illustrates both the depth of the problem and the difficulty of solving it. Even in a state with considerable resources, enlightened rhetoric, and multiple rounds of reform, the needle has barely moved for vulnerable kids. That reality should haunt policymakers and the public. It is simply unacceptable that in Massachusetts, and in any part of America, children in government care are no safer, and often less stable, than they were in the abusive situations from which they were removed. It is equally unacceptable that children known to be at high risk are left in abusive homes until they are killed. The promise of “child protective” services rings hollow when so many children continue to fall through the cracks.
What will it take to truly fix this? It will require more than cosmetic policy tweaks or fleeting bursts of funding after a scandal. It demands top-to-bottom cultural change within these agencies: genuine accountability, transparency, and a child-centered mindset at every level. Caseloads must be reduced so social workers can actually pay attention to each child. Supervisors must enforce quality standards rigorously. Whistleblowers and outside monitors need to be welcomed, not stonewalled. Family courts and child welfare proceedings need sunlight so that bad decisions can be corrected before they result in tragedy. And critically, there must be political will to prioritize child welfare consistently, not just when TV cameras are rolling. This means steady investment in preventive services to support struggling families before abuse happens, as well as swift, decisive action to rescue children in immediate danger. It also means providing children who are removed from their homes with truly safe, nurturing alternatives, not the current lottery of haphazard foster placements.
The children of Massachusetts, and of every state, deserve far better than they have been getting. Every child who dies or is irreparably hurt because a social worker ignored a file, or a supervisor shrugged off a red flag, or a judge rubber-stamped a reunification without scrutiny, every single one is a failure that stains our society. We should be enraged by these failures. We should demand that those in power answer for each lost child and not rest until the system stops devouring its young. Massachusetts’ DCF has blood on its hands from years of incompetence and indifference, and it is not alone. It is time to hold these agencies to their mission: to protect and cherish every child, not as a case number, but as a precious life. The lives at stake are literally our future, and we cannot afford one more day of complacency in the face of such a damning and compelling truth.
