An investigation has found that the death of an autistic Connecticut teenager from malnutrition was preventable and there were problems with the state child welfare agency.
The state Child Advocate's Office (OCA) released a report Tuesday on the February death of 17-year-old Matthew Tirado, of Hartford. When he died, the 5-foot-9-inch-tall Matthew weighed roughly 84 pounds.
Police charged Matthew's mother, Katiria Tirado, 33, with manslaughter and cruelty to persons in May.
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The report said Tirado had been previously accused of child abuse, educational neglect and had an open neglect case. Tirado did not appear or respond to the juvenile court child protection proceed and the state Department of Children and Families (DCF) closed the neglect case involving Matthew Tirado a month before his death, after his mother refused for almost a year to let a DCF worker see him.
Mattew's sister was also the subject of multiple DCF reports for physical abuse and educational neglect. She was removed from the Hartford Public Schools a few months before Matthew died to be "homeschooled".
"Neither child was attending school when Matthew died. This report will examine how Matthew, and then his sister, came to be hidden or invisible in the months prior to Matthew’s death," the OCA report reads.
On February 14, 2017, Tirado, called 911 at 2:53 a.m. that morning to report that her son was vomiting at an apartment on 519 Park St. and had "gallstones," police said.
"My 17-year-old son– I don't know what it is– but he might have gall-gall stones because he's been vomiting for the past 24 hours. Now his belly is bulging. But he hasn't urinated anything. I mean, I used to have gallstones before and I know what it feels like and how it looks like," the mother said during a 911 call that police released in March.
Matthew was brought to the hospital and pronounced dead hours later. Officials at the Chief State Medical Examiner reported that Matthew showed signs of significant physical abuse, including broken ribs, a laceration to his head, several contusions and bedsore-type injuries to his buttocks, and severe malnutrition, according to the report and police.
Tirado's arrest warrant details text messages from Tirado to her sister, which included a photo of the cabinets and refrigerator screwed closed. In the messages, Tirado told her sister that her son had been trying to drink cooking oil and ketchup.
State officials and police said Matthew's food was severely restricted and that he was allegedly beaten if he attempted to sneak food, according to the report.
The report claims the teen was very ill in the days leading up to his death, deteriorating and vomiting frequently, "but his mother allegedly delayed seeking medical attention for fear that Matthew's appearance would lead DCF to 'get involved' with the family."
Relatives were shocked by Matthew's appearance during a family party of Tirado's a week before his death, but didn't suspect physical abuse because they were told he had a "fast metabolism", according to the report.
The OCA said they spoke and reviewed records with DCF personnel, Hartford Public Schools officials, the Judicial Branch, Oak Hill School and the Office of the Chief Public Defender, to determine how Matthew's death could have been prevented.
The OCA found that Matthew's neglect and abuse dates back to 2005 when he was 6 years old. Between 2010 and 2014, there were no DCF reports regarding the Tirado family, however, Matthew was taken out of Hartford schools for months and even years at a time without being enrolled elsewhere. There was no inquiry from the school district.
In November 2014, Hartford Public Schools called DCF alleging education neglect since the boy had not enrolled in school for a long period of time.
"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 OCA report reads.
After April 2016, the Hartford school district was told by DCF that it intended to file a neglect petition on Matthew's behalf, but there is no documentation that the school district continued to follow up on the teen's non-attendance. There is no documented communication between DCF and Hartford Public Schools between May 2016 and the boy's death in February 2017, the report alleges.
The Juvenile Court held six short hearings on the Tirado family's case between July and December 8, 2016.
"In December 2016, the day before a court hearing and after nine months of not being allowed to see Matthew or verify his whereabouts, DCF submitted a written recommendation to the Juvenile Court requesting that the Court terminate the case and end Protective Supervision early. The paperwork did not spell out what efforts had been sought or made to find the children and ensure their safety. DCF did not allege that closing the court case served the best interests of the children," according to the OCA report.
In January 2017, the DCF closed its own case of the family.
"DCF’s risk,17 safety, and needs assessments completed on Matthew and his family between 2014 and 2016 were inconsistent and inaccurate, resulting in a lower assessment of risk to the children than actually existed. The erroneous assessment of Matthew’s risk of harm and his vulnerability to harm, affected the trajectory of his case until it closed," the report claims.
The OCA recommends the DCF to generate specific policies, training and case practice guidance regarding investigations of alleged abuse and neglect for children with developmental disabilities.
OCA also said that DCF does not enforce training requirements for staff and allege that workers interviewed provided varying and inconsistent information regarding training requirements for staffers.
In addition to training, the OCA suggests that the DCF's current information management system does not support consistent high-quality case management and said it may be part of the reason assigned staff lacked awareness of the details of the Tirado family's cases.
"This system is outdated, and it can be very time-consuming for line-staff to review and extract information that may be critical to assessment and case planning," the report reads.
DCF Commissioner Joette Katz said her agency lacked authority to force his mother to allow access to the boy.
"Nothing diminishes the heartbreaking nature of what happened to Matthew; the level of abuse inflicted by the mother and intentional denial of food are egregious and incomprehensible. In this particular instance, the mother repeatedly denied child welfare, school, and law enforcement officials, among others, access to Matthew. Lacking the authority to force the mother to cooperate and allow access to Mathew, none of these entities had evidence of the abuse that she inflicted on him," Katz said in a statement.
Katz said the agency is taking steps to improve DCF.
The Hartford Public Schools released a statement that said the district is working closely with OCA to develop framework to change how staff repors suspected child abuse and neglect.
"This report identifies failings in our culture to serve children, and within the district’s policies, procedures and practices regarding chronic absenteeism, internal processes and proper collaboration with external agencies," the Hartford Public Schools' statement said.
In addition, the school believes the state guidance for homeschooling must be strengthed and the district will now work with staff to determine any concerns when a parent is taking a student out of Hartford schools to be homeschooled. The staff will cross-check that student and family history with the DCF. The district is also developing a communication with parents of homeschooled children to be distributed twice a year in order to check up on the child's progress and education portfolio.
"Hartford Public Schools is grateful for the OCA’s dedication to its mission of protecting our children and we look forward to our continued collaboration. At Hartford Public Schools we have developed an Action Plan to address many of these concerns. The OCA’s findings and recommendations in this report are currently under consideration by Hartford’s Board of Education and will be incorporated into the district’s ongoing Action Plan to ensure student safety," Hartford schools said in a statement.