Note: This story has information that some may find disturbing or triggering.

BOSTON (WPRI) — The Massachusetts Office of the Child Advocate (OCA) determined there was a “multi-system failure complicated by the pandemic,” following an investigation into the October death of a disabled Fall River teenager and the alleged neglect of his brother.

The OCA released findings and recommendations Wednesday, which also stated safeguards in place, especially at the Department of Children and Families (DCF), “were inadequate.”

Last October, police responded to a Green Street home and found David Almond “emaciated, bruised, and unresponsive.” His brother, Michael was also suffering from “similar indications of abuse and neglect,” according to investigators. David and his brothers were each diagnosed with Autism Spectrum Disorder at an early age.

David was pronounced dead at the hospital, and Michael survived his injuries after being hospitalized for several months.

A younger half-sibling also found in the home appeared uninjured and physically unharmed.  

Earlier this week, the boys’ father, John Michael Almond, 33, and his girlfriend, Jaclyn Marie Coleman, 26, were indicted on charges of second-degree murder and neglect of a disabled person resulting in serious bodily injury.

The children have been under state supervision or care since 2013, originally with the New York Office of Children and Families.

New York authorities returned the triplets to Almond’s custody in 2016, who lived with his girlfriend and mother in what the OCA described as a “small one-bedroom apartment” in Fall River.

Less than a year later, the OCA says the Massachusetts DCF began investigating the family for substance use and abuse and neglect of the children. In October 2017, DCF removed the triplets and a younger half-sibling from the home.

Three years later, the triplets were living in a Massachusetts group home, when DCF began the process to return the teens to Almond and his girlfriend, who remained at the same Fall River residence. One of the three triplets opted not to return.

“The decision to reunify the children with their father and his girlfriend was a serious error that was compounded by the pandemic,” a news release from the OCA states. 

David and his brother, Michael, returned on March 13, 2020, just three days before Gov. Charlie Baker declared a state of emergency due to the pandemic.

In accordance with state laws, the OCA investigates both “the actions and inactions” of state agencies following any serious injury or death to a child receiving state services.

In its list of findings, the OCA says the decision of the area DCF office to return the boys home “was not clinically justified and failed to address the children’s special needs and safety.”

The OCA also says Almond and Coleman did not do enough after they were reunited with the children, and DCF staff did not evaluate whether the couple’s skills or behavior had improved enough to provide care to children with autism.

Additionally, the OCA found the Juvenile Court and the attorneys representing both the children and their caretakers “did not question DCF’s decision to return the children nor did they insist that a careful reunification plan be developed and approved by the Court prior to return.”

The start of the pandemic “exacerbated the situation by preventing in-person services and visits,” according to the OCA, and Almond and Coleman “continuously circumvented contact with DCF area office staff, the Fall River Public Schools, and other human service providers.”

The findings note DCF did not identify the family as being “high-risk” for future abuse or neglect, which would have required in-person home visits during the pandemic. This resulted in David and Michael being visited only virtually between March 2020 and David’s death in October. 

The OCA also notes even with virtual visits, DCF staff “missed many warning signs that David and Michael were in distress,” including a “visible wound on David’s face was seen by social workers and dismissed by Ms. Coleman as self-harm.”

The findings by the Office also place blame on the Fall River School Department (FRPS), saying the department’s “failure to provide David and Michael with the education they were entitled to is a direct result of the complexities of the COVID-19 pandemic.”

WBZ spoke with Fall River Superintendent Michael Malone, who said the findings were “hard to read.”

“You never want to accept that we could have done more, but we could have done more,” Malone told WBZ.

“I failed my responsibility because this happened under my watch, so I’m responsible,” Malone said. “This kid’s dead- I got to live with that. But I can also make sure that we’re doing more and more, making sure that we got eyes on, that we’re caring 24/7/365.”

As a result of the investigation, the OCA highlighted the need for changes, noting some of which will require legislative action or policy and procedure changes at the departmental level. Regarding schools, the OCA recommends:

  • The Department of Education (DESE) creating operational standards for addressing school attendance and the actions school districts must take when children fail to attend school.
  • School districts explicitly linking attendance in remote and hybrid models to the actual participation of students in their education and the following of all established policies and procedures for investigating and addressing attendance issues. 
  • DESE and DCF collaborating and determining how districts should ensure DCF has access to regular attendance updates for all students who are in the legal custody of DCF.

Fall River has already implemented changes in protocol including students must now have their cameras on for remote learning, a crisis team has been created to identify at-risk students, and training for all staff for signs of abuse and neglect.