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. Her father 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 three years and eight months due to neglect concerns, yet the children remained in their parents’ care with no improvements. The case never entered a courtroom and 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.
During a news conference on Wednesday, Maria Mossaides, Director of the Office of the Child Advocate, said, “Inadequate supervision, parental substance abuse, and failure to obtain pediatric medical care. This resulted in missed healthcare appointments, failure to address developmental delays, poor nutrition, social isolation, and unsafe housing.”
Mossaides added, “Despite all of this, DCF didn’t make any change to their case practice approach.”
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.
“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,” Mossaides said.
Mossaides noted that her recommendations require a financial investment, adding that the state shouldn’t balance the budget on the backs of the state’s most vulnerable children and 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.”
DCF responds
In a statement shared with Boston 25 News, the DCF vowed to address the concerns raised in the OCF report.
“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. DCF is committed to doing everything we can to enhance safety for children,” a spokesperson for the agency said. “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.”
Gov. Healey speaks out
“I really appreciate the OCA’s report and recommendations, and I know the agency [DCF] will take them into consideration immediately and work to take steps, anything and everything that needs to be done, to protect our kids,” Healey said.
What’s next
Francisco Ortiz, who has pleaded not guilty to charges in this case, is due back in court next week for a motions hearing.
A trial date has not yet been set.
Read the full OCF report:
This is a developing story. Check back for updates as more information becomes available.
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