Report of The Child Advocate to Governor Deval Patrick
Concerning the Disappearance of Jeremiah Oliver
January 23, 2014
The Office of the Child Advocate (OCA) received a Critical Incident Report on December
13, 2013, regarding the disappearance of five-year-old Jeremiah Oliver of Fitchburg,
Massachusetts. The Oliver family had been involved with the Department of Children and
Families (DCF) for over two years when social workers learned in December that Jeremiah
was missing and could not be located with family members in another state. Law
enforcement officers advised DCF employees on December 13, 2013, that they would treat
Jeremiah’s disappearance as a homicide investigation. On December 17, 2013, Jeremiah’s
mother Elsa Oliver was arraigned in Fitchburg District Court on two counts of reckless
endangerment of a child, two counts of accessory after the fact, and one count of assault and
battery with a dangerous weapon. She is being held in contempt of court for failure to
produce Jeremiah at a care and protection proceeding in the juvenile court. Ms. Oliver is
also detained for a mental competency evaluation and, should she resolve these matters, her
bail is set at $100,000 with conditions of release. Ms. Oliver’s boyfriend, Alberto Sierra, was
arraigned in Fitchburg District Court on December 16, 2013, on three counts of assault and
battery with a dangerous weapon and two counts of assault and battery on a child causing
bodily injury. He is being held without bail after a judge found him to be a danger to the
public. The Office of the Worcester County District Attorney, in collaboration with the
Massachusetts State Police Detective Unit and the Fitchburg Police Department, continues
to investigate crimes related to Jeremiah’s disappearance and possible death.
In response to Jeremiah’s disappearance, Governor Deval Patrick ordered the Commissioner
of DCF to investigate and report to him concerning DCF’s efforts on behalf of the Oliver
family. “The Department of Children and Families’ Investigation Report, December 30,
2013,” (the DCF report) was released to the public on that date and is available on the OCA
Website. The DCF report disclosed information about the social work services received by
the Oliver family and informed the Governor and the public that DCF had fired three
employees and disciplined another employee after reviewing their job performance. In
addition to these employment decisions, the DCF report identified actions the agency has
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 taken related to home visits, screening decisions, case reviews, and collaboration with other
state agencies and providers.
Governor Patrick requested that The Child Advocate conduct an independent investigation
into DCF’s work with the Oliver family. The OCA investigation included document review
and interviews with agency, union, and law enforcement personnel. The OCA is prohibited
by law from disseminating any confidential information obtained during the investigation of
critical incidents. For this reason, we will present only information related to the Oliver
family that is already known to the public through media reports or through the DCF report.
During the OCA’s investigation of this matter, the Patrick administration contracted with
the Child Welfare League of America (CWLA) to conduct an immediate quality
improvement review of DCF practices identified in the DCF report. The CWLA review will
examine DCF policies and practices regarding screening of reports of abuse or neglect,
assessment and service planning, identification of risk factors, home visits, removal of
children from the home, and case management. In addition, CWLA will review recent
recommendations made by DCF and the Executive Office of Health and Human Services
and assess how DCF policies, practices, and recommendations align with best practices. The
contract requires that CWLA submit a final report by March 14, 2014.
DCF Casework with the Oliver Family
According to the DCF report, the Oliver family became involved with the agency in
September 2011 after a 51A report was filed alleging neglect of the three children, then ages
two, five, and seven. The initial social worker assigned to the Oliver family met monthly
with family members and helped them connect with services over the next 15 months. After
the family relocated to Fitchburg, the Oliver family’s case was transferred from the original
DCF area office to the North Central Area Office (NCAO) in January 2013. The next social
worker assigned to the Oliver family did not make monthly home visits as expected and did
not refer the family for any services. The worker visited the Oliver home and saw the
children in February and April of 2013. In May 2013 a 51A report of abuse or neglect was
filed, investigated, and supported concerning Elsa Oliver’s physical abuse of her oldest child.
In June three 51A reports regarding a single incident were filed raising concerns about the
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 Oliver children and their mother; however, because an investigation had just been
completed, these reports were not assigned for investigation. Although managers believed
that the social worker assigned to the family would follow up on these new concerns, the
social worker did not do so. Elsa Oliver moved with her children to a different apartment in
Fitchburg and refused to give the social worker her new address when they spoke on the
telephone in late June.
When the social worker visited the two older children at their elementary school on
November 5, 2013, the children talked about their mother’s boyfriend and gave different
information about Jeremiah’s whereabouts. The worker attempted an unannounced visit at
the children’s home later that day but there was no answer at the door. On December 3,
2013, a mandated reporter filed a report of abuse or neglect and the ensuing investigation led
to the discovery that Jeremiah had not been seen by anyone outside the immediate family
since mid-September.
North Central Area Office
The North Central Area Office (NCAO) is one of the busiest DCF offices in the state and
consistently has one of the highest ratios of weighted caseloads to worker, averaging 18.53
weighted cases per ongoing social worker for the 12-month period ending October 2013.
Since 1986 the contract between DCF and the Service Employees International Union Local
509 (the union) has stipulated that an ongoing worker’s weighted caseload will be capped at
18. A weighted caseload assigns a higher value to cases that require more intensive action,
such as a new investigation or assessment. The high weighted caseload ratio at NCAO is the
result of a large increase in the number of open cases in the office combined with a high
number of full-time employees on approved leave (e.g., family medical leave). The efforts by
DCF management to increase staffing to help lower weighted caseload ratios appear to have
been offset by the steady and significant increase in new cases and staff leaves. In May 2013,
then-Acting Commissioner Olga Roche met with staff at NCAO to discuss ongoing
concerns, including the issue of high weighted caseloads.
A Memorandum of Agreement (commonly called a Memorandum of Understanding or
MOU) between DCF and the union was signed on March 18, 2013, and ratified by the union
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 in April 2013. The MOU specifically addresses caseload standards for ongoing social
workers. Rather than weighting and capping caseloads based on the single measurement of
number of families, the MOU provides that caseloads will be based on three measures: no
more than 15 families, no more than 28 children, and no more than 10 children in out-ofhome placements per worker. Full implementation of the MOU is contingent on the
availability of funding for additional social workers. After the Fiscal Year (FY) 2014 budget
was passed without an appropriation for implementation of the MOU, DCF and union
representatives began meeting in September to discuss actions that would move DCF
toward realization of the 15 families, 28 children, 10 children in placement measurements
without additional funding. As of early December 2013, DCF and the union were exploring
various options to try to equalize caseloads between and within offices.
During the period from May to October 2013, the union filed a grievance on behalf of the
social worker assigned to the Oliver family every month due to weighted caseloads over the
average of 18 negotiated in the union contract. DCF measures weighted caseloads for social
workers on the last day of every month and showed the worker’s weighted caseload to be
above 18 in June, July, August, and October.
DCF Budget and Staffing
The global recession of 2009 reduced state revenues and resulted in budget cuts throughout
state agencies. The DCF budget was reduced drastically from a high of $836.5M in FY09
(later reduced by $20.2M due to 9C cuts) to a low of $737.1M in FY12. While the budget
did increase to $759.3M in FY13 and further increased to $779M in FY14, the vast majority
of this additional funding was absorbed by increased foster care rates, Chapter 257 human
service provider rate reforms, and collective bargaining salary increases for unionized
workers, including social workers.
A decision to preserve frontline social worker positions in the face of budget cuts,
particularly in FY11, resulted in an overall reduction during the period FY09 to FY14 of 47
managers at the area, regional, and central office levels (17%) and 124 social workers (5%)
statewide. These numbers reflect layoffs and attrition with limited ability to hire for
positions left open by retirement or resignation. An October 2010 restructuring of the 29
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 DCF area offices reduced the number of regions from six to four. Half of the Area Director
positions were eliminated, so that each Director of Areas oversaw two area offices. The
reduction in management created additional demands and pressure on both managerial staff
and the supervisors and social workers who look to them for help. Area Program Managers
(APMs) are the first level of nonunion management and are responsible for direct clinical
and administrative operations of an area office. One top manager remarked that, “APMs are
busy 100% of every day.” With the reduction in managers, the ability of APMs to monitor
the supervisors necessarily diminished, as APMs were less available to discuss concerns, act
as resources for clinical management, and manage personnel issues. Quality assurance
functions, including case reviews, are led by managers, and the loss of 47 managers
compromised those functions as well. Finally, even when DCF can hire a new manager, the
hiring and approval process takes months, so each managerial vacancy left the affected area
office with ever more demands on the existing staff.
OCA Observations
The DCF report identified the agency’s actions and plans to improve processes and systems,
and this report will not duplicate that information. The OCA offers the following additional
observations:
Child Protective History in Other States:
The Oliver family had a history of serious child protective concerns in another state that did
not follow the family to Massachusetts. Although DCF investigators in Massachusetts were
aware of this history and requested more information in 2011, the child protective agency in
the other state did not respond. After Jeremiah’s disappearance in 2013, the sister state
agency sent selected records to DCF. It is critical that child protection records be made
available to other states in appropriate circumstances, such as during investigations, so that
social workers can assess the risk and safety of the child.
Case Transfers between Area Offices:
When a case is transferred between area offices, DCF policy states that “when appropriate, a
case conference involving the sending social worker and supervisor and receiving social
worker and supervisor should be held. In situations where this is not possible, the newly
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 assigned supervisor and the sending supervisor should conference the case on the
telephone." No transfer meeting or telephone call was held between workers or managers in
the original DCF area office and NCAO for the Oliver family. DCF policy also requires the
social worker and supervisor to review the case record, but the DCF report states the worker
only read the transfer summary and the supervisor did not read the entire case file. These
lapses – no record from the other state, no transfer meeting or phone call, and incomplete
record review by the social worker and supervisor – compounded one another, so that the
social worker and supervisor at NCAO had limited information about a family that had been
involved with protective services in two states over six years.
Previous Critical Incident from NCAO:
The OCA received a critical incident report in 2012 concerning the Jones family (a
pseudonym) documenting serious injuries inflicted on a two-year-old child by the mother’s
boyfriend. When OCA staff visited NCAO to discuss the Jones family and case practice
with DCF managers, the managers identified a number of missed opportunities in the
casework. The same social worker from NCAO assigned to the Jones family was later
assigned to the Oliver family. In this context, one would have expected the manager to
construct a concrete plan for the social worker outlining heightened supervision
requirements, monitoring, and training until she demonstrated that she had incorporated the
lessons learned by the area office after the Jones child was injured. However, this did not
occur.
The Social Worker’s Responsibility:
Frontline social workers are fundamental to the effectiveness of DCF. The children and
families, the supervisors and managers, all depend on the social worker's investment in the
family and the worker’s ability to continually assess and effectively evaluate risks and
protective factors. The worker assigned to the Oliver family was focused on those cases she
believed were in crisis, including the cases of other workers in her unit. From her
perspective, she was in the trenches with her co-workers, making sure that she was available
to help them manage crises in their cases and knowing that they would be available to her if
she needed them. In this way, her professional gaze drifted from the children within her
own caseload and she lost touch with the truth that she was the person responsible for
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 visiting those children, knowing them, and ensuring their safety. A professional must find a
way to meet basic obligations even when the workload is difficult. Everyone at DCF agrees
that the most basic obligation is to “visit your children.” This is the cornerstone of
protective work and the worker’s consistent failure to visit the Oliver children cannot be
excused. The social worker was fired as a result of Jeremiah’s disappearance and the
resulting review of her work.
The Supervisor’s Responsibility:
Supervisors are critical to DCF. They are responsible for the direct oversight of social
workers and share responsibility for understanding and responding to a family’s needs. In
this instance, the supervisor did not help the worker set priorities within her own caseload to
ensure that she got the basics done. The supervisor was aware that the worker had not
visited the Oliver family for months but did not insist or ensure that the visits happened.
When the Area Program Manager inquired about the visits, the supervisor made excuses for
the social worker. As a result, DCF’s supervisory structure failed Jeremiah Oliver. The
supervisor was fired as a result of Jeremiah’s disappearance and the resulting review of her
work.
The Area Program Manager’s Responsibility:
Supervisors are in turn supervised by Area Program Managers. APMs are responsible for
direct clinical and administrative operations of an area office, including the quality of
casework services and personnel management. APMs are nonunion employees, while both
social workers and supervisors belong to the Service Employees International Union Local
509. The relationship between the supervisor and the APM in this instance was strained,
and this led to ineffective supervision. The APM was aware that the social worker needed to
visit the Oliver children and she directed the supervisor to make sure the worker visited the
children in September and October. The supervisor told the APM that the worker had
visited the children and needed to catch up on her dictation in the case record, while in turn
directing the social worker to visit the Oliver children. It is achingly frustrating to look back
and see that the APM directed the supervisor who directed the worker to perform her most
fundamental responsibility – yet it still didn’t happen. In this instance, DCF’s supervisory
structure failed to identify the problems with casework that supervision is intended to
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 highlight. The APM was fired as a result of Jeremiah’s disappearance and the resulting
review of her work.
Home Visiting Reports:
DCF uses a statewide data report to ensure that children and families are visited on a
monthly basis. Home visit reports measure social worker compliance in completing home
visits and provide the date of the last documented home visit. These reports are generated
by DCF twice monthly and are provided to all DCF Area Office managers and supervisors.
At NCAO, home visit reports are used at all levels of management and NCAO has
demonstrated a compliance rate close to the state average (NCAO 81.4% vs. state 82.5% for
12 months ending November 20, 2013 ) with the expectation of monthly home visits for all
children on a worker’s caseload. The home visit reports list the date of the social worker’s
last home visit and the names of the parents and children. The Oliver family was last visited
in their home by the social worker on April 30, 2013. This date and the names of the family
members appeared on the June 15, 2013, home visit report and on every home visit report
thereafter through December 1, 2013. The worker’s lack of compliance was evident to
managers through the home visit report and was regularly brought to the attention of both
the supervisor and the social worker. The DCF system of generating and utilizing home visit
data reports can be a useful tool to monitor compliance regarding home visits. In the case
of the Oliver family, the home visit reports accurately reflected the date of the worker’s last
home visit and alerted the APM and supervisor to the need for an immediate home visit.
However, the social worker failed to visit the family despite this additional layer of oversight.
Managing by data is invaluable – and yet only as valuable as the ability of the workforce to
use the information constructively and to provide direction effectively.
Agency-Wide Review of Children under Six:
During the months of August through October 2013, DCF conducted an agency-wide
review of cases with children under age six who remained in the care of their parents. The
purpose of this review was to ensure the safety of young children. Accordingly, the
supervisor and social worker met on September 20, 2013, to review the safety of the Oliver
children. As specified in the DCF report, the supervisor entered a misleading note in the
case record that did not reflect the current status of the casework. This undermined a crucial
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 opportunity to identify the Oliver children as needing immediate attention. The supervisor
and social worker appeared to view the agency-wide review as one more task from
management that they could not satisfy, rather than viewing it as a tool for ensuring the
safety of children.
Screening Decisions in Ongoing Cases:
The DCF report documents that three 51A reports of abuse or neglect (two by mandated
reporters) pertaining to the same incident were filed in June 2013 but were screened out.
The Intake APM who made the screening decision was disciplined through a 3-day
suspension without pay and a change in job responsibilities. In addition, before the case
with the Oliver family was transferred from the original area office to NCAO, a report of
abuse or neglect by a mandated reporter was filed in January 2013 and was screened out by
an APM in the original area office.
When a new report of abuse or neglect is filed concerning a caretaker who has an open case
with DCF, it is the responsibility of the Intake APM to decide whether the report will be
screened in for assessment or investigation. An investigation is performed by a different
social worker with additional training who re-evaluates the protective concerns within the
family. Screening out reports of abuse or neglect filed by mandated reporters discourages
these professionals who work with children from reporting concerns to DCF. These four
instances of screened-out reports represent missed opportunities for re-evaluation and
intervention with the Oliver family in contravention to DCF policy. We can appreciate the
desire to use the existing resource of the ongoing social worker as a follow-up to reports of
protective concerns, but we also recognize the value of the intake unit and the specialized
protective lens they bring. In both January and June 2013, the allegations in the reports
merited an investigation and should have been screened in.
The DCF report lists as a process improvement the following: “The Commissioner is
directing the Department to screen in for investigation and intensive case management any
report alleging abuse or neglect about a family with a child five years old or younger which
presents any, or a combination, of the following risk factors: young parents; or parents of
any age which have a history of substance abuse, domestic violence, mental health issues, or
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 unresolved childhood trauma.” This action would require additional social workers,
supervisors, and managers to implement and should be examined during the CWLA review
of DCF policies.
Discussion
How can a social worker not notice when a five-year-old boy on her caseload disappears?
One of the top managers from NCAO said, “I didn’t think something like this could happen
in our office with our systems.” The same manager also said, “We have ridiculously high
caseloads, but that’s not what this is about.” The high weighted caseloads at NCAO provide
a context rather than an explanation or excuse for repeated failures. When we expect more
of everyone in a system, we may see increased performance for a period of time – but
eventually everyone will have contributed the extra effort they have to give, and continued
expectations for ever-increasing performance may not be met.
The weighted caseloads of all social workers at NCAO deserve consideration. In a busy
office with high caseloads all around, each worker is scrambling to keep up. Workers are
called on to help one another; supervisors have responsibility for more workers with more
cases; APMs supervise a cascading number of clinical cases through the supervisors and
workers. In the ever-increasing push for workers to handle more cases, the system becomes
more crowded, the pressure builds, and the opportunities for clinical social work and
thoughtful supervision diminish. Families with complex problems receive less attention and
their children, already identified as having been abused or neglected, suffer.
A good child welfare system needs it all – a skilled workforce with manageable caseloads,
staff committed to meeting their professional obligations, knowledgeable and supportive
supervisors, seasoned managers, plus support, training, and quality assurance. There is no
shortcut to creating this system but DCF has already charted a course to reduce caseloads
through its MOU with the union. This is the first step to rebuilding the resources that
would be required by any system that delivers complex services every day of the year to
families in crisis. And of course, to their children.

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 Recommendations
1. The weighted caseloads at NCAO in 2013 were among the highest in the state. These
high caseloads created highly stressful conditions at NCAO and were a contributing factor in
the failure of the social worker and her supervisors to carry out fundamental protective
casework and supervisory responsibilities. Governor Patrick’s FY15 budget provides the
necessary resources to permit the assignment to each social worker of no more than
15 families, no more than 28 children, and no more than 10 children in out-of-home
placements. It is vital that this level of funding be supported by the Legislature.
2. Excessive caseloads do not excuse the specific failures that prevented DCF from
discovering Jeremiah Oliver’s disappearance. DCF supervisors and managers failed to
prioritize their limited resources in a manner calculated to do the least harm to children and
families. Precisely because of concerns about high caseloads, DCF should have had a plan in
place for triaging its services. Indeed, such a plan should always be in place. It is not
enough to request additional funding; even an inadequate budget must be spent in a manner
that does the most good and the least harm. We urge DCF to develop a protocol to
establish priorities when caseloads exceed acceptable levels.
3. CWLA has been engaged by the Patrick administration to conduct an immediate quality
improvement review of DCF policies, practices, and recommendations identified in the DCF
report and how these align with best practices. During the course of its investigation, the
OCA identified specific existing DCF policies and practices that warrant further
review by CWLA. These include case transfers between offices, case reviews,
ongoing casework, case closing criteria, and information sharing between DCF and
child protection agencies in other states.

~ ~ ~

Let’s end by remembering Jeremiah – a bright, articulate little boy who loved strawberries and
cornbread and who loved to sing.

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