Mass. DCF missed warning signs, girl suffered ‘chronic neglect’ before death, report says

WORCESTER, Mass. — A new report from the Massachusetts Office of the Child Advocate reveals critical gaps in child protection practices following the death of 4-year-old A’zella Ortiz, of Worcester, whose case officials say underscores systemic issues within the Massachusetts Department of Children and Families.

A’zella was found unresponsive in a Sever Street apartment on October 15, 2024, and was later pronounced dead. Her siblings, ages six and two, were discovered severely malnourished and injured. The Office of the Chief Medical Examiner ruled A’zella’s death a homicide caused by multiple blunt force injuries. Her father, Francisco Ortiz, is currently jailed and facing charges including murder and child abuse.

Worcester investigators say when they responded to a 911 call in October 2024, they found A’zella lying on the floor, cold to the touch, with feces covering parts of her body. Francisco Ortiz allegedly told police A’zella fell from a table, but investigators say her injuries were consistent with a two-story fall.

Officers say they also found A’zella’s siblings in the home. They say a two-year-old sibling had a skull fracture. A six-year-old sibling tested positive for fentanyl. Investigators say the older child was non-verbal and had never been to school.

According to the 65-page OCA report, DCF had been involved with the family for nearly four years due to neglect concerns, yet the children remained in their parents’ care. The case was closed in October 2023, just one year before A’zella’s death.

25 Investigates’ Kerry Kavanaugh first reported in October that DCF had a history with the little girl’s family.

“The vast majority of children served by DCF are living at home, with their families. Our goal as a Commonwealth should be to ensure that these children can stay home safely. For that to happen, state intervention with families where maltreatment has occurred must be child-centered, based on an accurate assessment of risk, time-limited, and serve to support and stabilize the family. Unfortunately, that is not what happened in this case, with tragic results for A’zella and her siblings,” Maria Mossaides, Director of the Office of the Child Advocate, said in the report.

A review of critical incidents involving children in Massachusetts falls to the OCF. 25 Investigates has been asking for the results of that review of A’zella’s case since late last year.

Those answers were revealed on Wednesday morning:

Key findings

• Missed warning signs: Risk assessments escalated from “low” to “very high” over time, but DCF did not adjust its approach.
• Static casework: Six action plans were issued, yet tasks remained unchanged despite a lack of progress.
• Inadequate oversight: Monthly home visits were completed, but engagement was superficial and repetitive.
• Case closure missteps: The family was “missing” for three months before DCF closed the case, having not seen the children for 114 days.

The report concludes that neglect in the home escalated into chronic neglect, compounded by parental substance use and social isolation. Both surviving children are now in state custody and receiving intensive medical and developmental care.

“Physical abuse and chronic neglect led to the death of A’zella and profound physical and developmental impacts on Luna and Mateo,” the report stated. “Physical abuse, as far as we can know, occurred after the DCF Area Office’s involvement with the family and concurred with the chronic neglect.”

Systemic issues

The OCA warns that this case reflects broader concerns:

• No structured quality assurance framework for intact families, which make up 78% of DCF’s caseload.
• Lack of accountability for following through on recommendations.
• Misinterpretation of “reasonable efforts” to prevent child removal.

Recommendations

The report calls for sweeping reforms, including:

• Revising the DCF Case Closing Policy.
• Creating a stand-alone policy for clinical specialist consultations.
• Strengthening the definition and use of clinical formulation.
• Conducting a training needs assessment focused on child development, parental engagement, substance use, and neglect.
• Addressing chronic neglect as a distinct subset.
• Establishing a structured quality assurance framework for intact families.

Dedication in A’zella‘s memory

The OCF dedicated a blank space on page 4 of the report because so little was known about A’zella.

“The OCA’s knowledge about A’zella Ortiz as a person is extremely limited. She did not attend childcare or activities and did not have any significant personal connections we know about other than her immediate family. She had an older sister and a younger brother; she was the middle child. She had an extremely strong bond with her siblings. She also had a love of the show CoComelon, a cartoon family that sings child-focused songs together. A’zella’s personality, interests, and life experiences are largely unknown to the Office of the Child Advocate (OCA). The record does not tell us much about this precious little girl. We dedicate space here in remembrance of her life and to acknowledge her loss.”

Boston 25 News has reached out to DCF for comment on the OCF report.

Read the full OCF report:

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