The Massachusetts Department of Children and Families failed to properly recognize warning signs or effectively intervene with parents prior to the death a 4-year-old Worcester girl, according to a newly released investigation.

The Office of the Child Advocate released its findings and recommendations for DCF changes Wednesday, part of year-long investigation into the death of A'zella Ortiz.

The 4-year-old, who investigators say died from blunt force injuries was found in a Worcester apartment in October of 2024. Her two siblings were also hospitalized at the same time with signs of abuse and neglect.

A'zella's father, Francisco Ortiz, has been charged with her murder and is being held in jail awaiting trial.

"The children experienced neglect in the care of their parents that was chronic and cumulative, including inadequate supervision, parental substance abuse and failure to obtain pediatric medical care," said OCA Director Maria Mossaides.

Timeline of DCF Involvement

The OCA says DCF first opened a case into the Ortiz family in October of 2018, after receiving a report that A'zella's older sister was born substance exposed. That case was closed in 2019, but subsequent cases were opened in 2020 after reports were received about A'zella and her younger brother.

"DCF created six different action plans and met with the family 36 times in three years. The substance of those visits changed very little from one to the next," said Mossaides.

According to the investigation, the family was no longer cooperating with DCF, who last saw the children in their home in June of 2023. In August 2023, A'zella's mother told the case management team they were staying in New York.

In September of 2023, a DCF social worker contacted New York CPS to make a report. New York reportedly indicated there was not enough information to register a report of concern.

In October of 2023, DCF officially closed their case. At that point, DCF's management team had not seen the children for 114 days prior to closing the case.

According to the OCA's findings, the family was only in New York for three weeks, before heading back to Worcester.  

In October of 2024, A'zella was pronounced dead in Worcester.

"Over the course of DCF's involvement with the family, the risk to the children escalated, and however, the DCF case management team did not reevaluate their approach to determine if a different strategy was required to engage the family and secure the safety of the children," said Mossaides.

Recommendation for changes

Mossaides' investigation didn't single out DCF workers or leaders, adding they followed existing procedures in place, but because of that she is recommending significant policy changes. Particularly in cases where children like A'zella remain in family custody.

"Despite the fact that 78% of the families served by DCF are intact families. Guidance and policy is minimal with almost no mandatory requirements for social workers or required quality assurance processes," said Mossaides. "This is despite the fact that these cases involve neglect, which makes the majority of these cases and can be particularly challenging to manage."

OCA's recommendations to DCF include:

• Revise and update the DCF Case Closing Policy
• Establish a structured quality assurance framework  
• Develop a stand-alone policy about case consultations
• Strengthen the definition of clinical formulation
• Create and embed an understanding of chronic neglect in DCF casework
  
• Conduct a training needs-assessment of the DCF workforce to systematically identify the knowledge, skills and capacity gaps.  

"The death of any child is devastating. We are heartbroken by the loss of A'zella, and we appreciate the Office of the Child Advocate's examination of this case," reads a statement from a DCF spokesperson.  "DCF is committed to doing everything we can to enhance safety for children.  We will address the concerns raised by the OCA, including reviewing our policy when we are considering closing a case, assessing training needs, and providing clearer guidance on assessing families for risk factors commonly associated with child abuse and neglect."

Funding gap

In calling for changes, the Office of the Child Advocate is also asking for DCF support from the State House.

"While I believe considerable progress has been made over the past decade, the report we are releasing today also demonstrates that the work is not complete," said Mossaides, who is set to leave her post in the coming weeks.

"I recognize that the upcoming budget will be difficult, but it will be a terrible mistake to balance the budget on the back of the most vulnerable children and families consider seriously the investment that it requires to ensure that our children are safe and have the opportunity to thrive. Our children are worth it," said Mossaides in calling for more funding to help address the gaps highlighted in the recent report.

Mossaides believes more funding is needed to bolster training, lower the number of caseloads per social worker, ensure quality assurance framework and to continue providing community-based services.  

"Supporting and stabilizing families so that children can safely remain at home is a critical goal, but it requires resources," she added.