A 17-year-old Hartford youth with autism died from starvation, dehydration and child abuse in February, just weeks after the Department of Children and Families closed its case file on him, an investigative report released Tuesday by the state’s child advocate said.
The report criticized several state agencies it said had not taken sufficient action, including DCF, the Hartford Public Schools and the juvenile court.
The Office of the Child Advocate’s nearly 80-page report said Matthew Tirado had been absent from school for months and his mother had been known to DCF for years.
Child Advocate Sarah Eagan said her report’s main takeaway is that there is an inadequate safety net for children with developmental disabilities.
The report states DCF lacks specific policies and guidance for its staff regarding investigations of alleged abuse and neglect of children with developmental disabilities. It coupled that with criticism of DCF’s outdated information management system, and the shifting of the Tirado family’s case among multiple workers and supervisors.
DCF had an open case on the Tirado family from October 2014 until this past January, but according to the child advocate’s report, only filed a neglect petition in the Juvenile Court in July 2016.
A DCF caseworker didn’t follow multiple directives from supervisors from that July until December 2016, including confirming the family’s whereabouts, requesting a police well-child safety check, and following up with the school system, among other instructions, the report said.
Gary Kleeblatt, a spokesman for DCF, said officials closed the case because there was no evidence of abuse or neglect available to the department.
DCF officials said the only confirmed findings regarding Matthew concerned his failure to attend school on a regular basis. They said the schools, DCF’s social workers and the court-appointed lawyer for the children were all denied access to Matthew.
DCF officials noted getting a court order to get access would require presenting evidence to show that the child was at serious risk.
“No orders were sought from the juvenile court, by DCF or by the children’s attorney to keep the case open until Matthew was found, compel production of the children, permit visitation of Matthew’s sister in school, or seek commitment of either child to state custody — despite grounds for such orders,” the report said.
Eagan’s office found that reports filed with the juvenile court days after Matthew’s death stated he was emaciated when he died, weighing only 84 pounds. The Office of the Chief State Medical Examiner found that Matthew had multiple broken ribs, a laceration to the head, several bruises and contusions on his upper body, among other things.
Katiria Tirado, Mathew’s mother, had cell phone pictures that showed she locked and shuttered her refrigerator and kitchen cabinets. The report stated Matthew was forced to seek food from the garbage and “would drink cooking oil, ketchup, and syrup if these items were accessible.”
Katiria Tirado has since been charged with first-degree manslaughter and intentional cruelty to persons in connection with Matthew’s death.
The report also found systemic issues in Hartford Public Schools, saying the school system’s own reports showed there were hundreds of children with disabilities who were chronically absent. There is “an inadequate framework in Hartford, and statewide for ensuring the safety of and education for children who are withdrawn from school to be home-schooled,” the report said.
The detailed investigation chronicles DCF’s involvement with Matthew dating back to 2005. Despite a period of no reports between 2010 and 2014, Hartford Public Schools called the department in November 2014 alleging long-term educational neglect by his mother.
“Records show that Matthew remained out of school for most of his life between June 2012 through his death in February 2017 without adequate intervention or response by state or local authorities, and, for multiple years, without anyone noticing,” the report said.
In November 2016 Matthew’s mother filed papers with Hartford Public Schools allowing her to withdraw his sister for home-schooling. The report states Hartford Public Schools officials didn’t notify DCF of her withdrawal despite “having made five child protection reports to DCF … regarding this child and her brother Matthew.”
Hartford Public Schools said in a statement the district has been working closely with the Office of the Child Advocate and other agencies to revamp systems and protocols intended to protect students.
“This report identifies fallings … within the District’s policies, procedures and practices regarding chronic absenteeism, internal processes and proper collaboration with external agencies,” the statement said.
Eagan said the investigative report was meant to examine whether Matthew’s death was preventable and detail urgent changes needed by state and local agencies moving forward.
The child advocate said the various agencies need to improve their ability to protect and serve children with developmental disabilities, noting that population is uniquely vulnerable to child abuse.
Eagan said she thinks cases involving abuse typically get closed either because of a conclusion that children are not in danger or those involved feel their tools have been exhausted.
“There were many risk factors either unknown or unrecognized,” Eagan said.
The child advocate said the legislature should broaden DCF’s ability to ensure the safety of a child alleged to be the victim of maltreatment. Eagan said the law limits the state’s authority to speak with or evaluate a child who may be at risk of abuse without permission of the parent.
Senate Republican leader Len Fasano of North Haven called on Gov. Dannel P. Malloy to fire Joette Katz, the commissioner of DCF.
“Katz has got to go. She’s got to go,” said Fasano, a critic who has repeatedly demanded Katz’s removal. “This governor has to do it. I want him to fire her. Apparently, she won’t resign, so just fire her. ‘You are terminated. You are gone.’ ”