FALL RIVER, MASS. (WHDH) - The Massachusetts Office of the Child Advocate identified a multi-system failure prior to the death of a 14-year-old Fall River boy with special needs.

The state agency announced their findings into the death of David Almond on Wednesday, just days after a Bristol County Grand Jury indicted John Almond and Jacyln Marie Coleman on charges of second-degree murder and neglect of a disabled person resulting in serious bodily injury in connection with this case.

David and his triplet brothers were each diagnosed with Autism Spectrum Disorder at an early age and due to abuse and neglect were under the consistent supervision or care of the New York Office of Children and Families from 2013 to 2016, according to the OCA.

New York authorities returned the triplets to the custody of their father, John Almond, in 2016, and he brought them to live with him, his girlfriend Jaclyn Coleman, and his mother in a small one-bedroom apartment in Fall River Massachusetts, the OCA continued.

The Mass. Department of Children and Families reportedly began investigating the family for substance use and abuse and neglect of the children less than a year after they moved to Fall River.

In October 2017, DCF removed the triplets and a younger half-sibling from the home, the OCA said.

The triplets were living at a group home in Mass. in early 2020 when DCF began the process to return them to John Almond and his girlfriend, who still lived in the one-bedroom Fall River apartment, the OCA added.

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

One of the triplets reportedly opted not to return to his father’s custody; however, David and his brother Michael returned on March 13, 2020.

Gov. Charlie Baker declared a state of emergency due to the COVID-19 pandemic three days later.

On Oct. 21, 2020, emergency crews responding to the Fall River apartment say they found David emaciated, bruised and unresponsive, as well as Michael suffering from similar indications of abuse and neglect.

The brothers were taken to a nearby hospital, where David was pronounced dead.

Michael was hospitalized for several months but survived his injuries.

The younger half-sibling who was also in the home appeared uninjured and physically unharmed, the OCA said.

John Almond and Jacyln Marie Coleman were indicted Friday on charges of second-degree murder and neglect of a disabled person resulting in serious bodily injury, Bristol District Attorney Thomas M. Quinn III announced.

Fall River death
Jacyln Marie Coleman and John Almond

Coleman was also indicted on a charge of withholding evidence from an official proceeding after authorities say she attempted to destroy a cellphone in the presence of a police officer.

The OCA investigated the actions and inactions of state agencies following David’s death and found several failures, which are listed below:

  • The DCF area office decision to return the boys home was not clinically justified and failed to address the children’s special needs and safety.
  • Mr. Almond and Ms. Coleman minimally engaged in the services required to support reunification; DCF area staff did not evaluate whether Mr. Almond or Ms. Coleman’s behavior and skills had improved to be able to parent children with autism. The Juvenile Court and the attorneys representing the caretakers and the children 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 COVID-19 pandemic exacerbated the situation by preventing in-person services and visits. Mr. Almond and Ms. Coleman continuously circumvented contact with DCF area office staff, the Fall River Public Schools, and other human service providers. DCF area office did not adequately assess the effect that the pandemic had on this family, especially in light of the family’s history of abuse and neglect.
  • DCF area office staff 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. As a result, David and Michael were never seen in-person and instead were visited only virtually between March 2020 and David’s death in October. The DCF high-risk criteria that was issued during the pandemic to identify families that required in-person visitation did not specify a child’s disability as a risk factor.
  • DCF area office staff missed many warning signs that David and Michael were in distress. For example, Mr. Almond and Ms. Coleman prevented the boys from attending any in-person or remote school, did not allow service providers to see or speak with David or Michael, and often prevented the boys from answering questions when they were seen virtually once a month by social workers. During one DCF virtual home visit, a visible wound on David’s face was seen by social workers and dismissed by Ms. Coleman as self-harm. Service providers raised concerns about the lack of engagement and what appeared to be the boys’ regression in function.
  • Fall River Public Schools (FRPS) failed to provide David and Michael with a free and appropriate public education between March 2020 and David’s death in October 2020 because neither David nor Michael received any academic instruction or related special education service. The FRPS 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.

“The OCA has determined that there was a multi-system failure, complicated by the pandemic, and that the safeguards that were in place, especially at DCF, were inadequate,” the state agency said.

The OCA highlighted areas that need to be changed within DCF, including having them redesign their reunification process, conduct a comprehensive review of their own practices, and improve its quality insurance infrastructure.

The OCA also recommended that the Mass. Department of Elementary and Secondary Education create operational standards for addressing school attendance and the actions school districts must take when children fail to attend school.

They added that the Juvenile Court should play a more active role in analyzing the merits of propose reunification cases, and that they should more strictly ensure that the circumstances that led to DCF’s original decision to remove children from their home are completely resolved before allowing reunification to occur.

“We feared when this pandemic began, that families would experience economic, social and other stressors, and that vulnerable children would suffer from lack of interaction with trusted adults, and that is tragically what happened in this case. David Almond was a vivacious, smart, and fun-loving boy who was often described as the ‘mayor’ of his former school. His impact on those who worked with him and loved him was profound and everlasting,” said Maria Mossaides, Director of the Office of the Child Advocate. “Child welfare professionals have the most difficult job – one that is filled with challenging decisions and trying circumstances. We need to strengthen our systems so that the missteps that occurred in this case are never repeated. While there is nothing we can do to bring David back, we do have the opportunity to honor his memory by making permanent changes that will protect other children. My office is committed to ensuring that this important work takes place.”

The OCA says they plan to work with public agencies involved in this case, Governor Charlie Baker and the state legislative leadership in the coming months to implement their recommendations.

The OCA’s full report can be found here.

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