Report finds death of malnourished, abused teen's was 'preventab - WFSB 3 Connecticut

Report finds death of malnourished, abused teen's was 'preventable'

Posted: Updated:
A report was released on the death of Matthew Tirado. (WFSB file photo) A report was released on the death of Matthew Tirado. (WFSB file photo)
Katiria Tirado. (Dept. of Corrections) Katiria Tirado. (Dept. of Corrections)

A recently-released report states the death of a malnourished abused teen, who had autism, was "preventable." 

On Tuesday afternoon, the Office of the Child Advocates released an 84-page report on the death of 17-year-old Matthew Tirado. Matthew Tirado was just 84 pounds when he died on Feb 14. 

“It’s a horrible tragedy," Faith VosWinkel with the  Office of the Child Advocates said. 

Matthew Tirado's death was ruled a homicide by the Office of the Chief Medical Examiner. Suspicious body trauma including broken ribs, a cut on his head and scarring, was found on Matthew Tirado and what appeared to be a severe case of malnutrition 

Katiria Tirado, who brought Matthew Tirado to the hospital, was arrested and charged with first-degree manslaughter in his death.  

"Matthew was a very vulnerable child and the systems that were designed to be in place and be a safety net for him were not, "VosWinkel  said. 

The purpose of the report, which is in honor of Matthew Tirado, was to do the following:

  • answer questions regarding how this child, known to several local and state agencies, died from abuse and neglect
  • examine gaps that may exist in the safety net for children with disabilities and recommend improvements in policy and practice to prevent future tragedies. 

The report by the Office of the Child Advocate states Matthew Tirado's death was "from prolonged child abuse and neglect." The report states Matthew Tirado "was unable to protect himself from harm," due to "his intellectual and developmental disability." 

Officials with the Office of the Child Advocates said all the systems including education, child welfare, and legal that served Matthew Tirado "must improve their ability to support and protect children with disabilities."

"Nothing speaks more profoundly to the need for systemic improvement than the fact that a child who had already been identified as a victim of abuse and neglect went unseen for almost a year prior to his death from child abuse. While this report outlines what various individuals did or did not do with regard to their interactions with Matthew and his family, OCA finds that the over-arching and urgent concern is the lack of clear capacity within aspects of our child-serving systems for responding to the special needs of children with disabilities," the report states. 

To read the full report, click here

“I think everyone recognizes this as a problem that we need to pay greater attention to," VosWinkel said. 

The child advocate's report said Matthew Tirado had a history with the state Department of Children and Families as an alleged victim of abuse and neglect dating back to 2005. DCF closed their case into him a month before his death despite never seeing him in person for nearly a year.  

    "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. With that said, despite the limitations on what actions the Department can take in light of parental resistance, the Department has taken steps to improve the work of our agency,"  DCF Commissioner Joette Katz said in a statement on Tuesday.  

    “In December 2016...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 repro

    DCF said Katiria Tirado repeatedly denied access to Matthew Tirado. DCF officials added, “despite the limitations on what actions the Department can take in light of parental resistance, the Department has taken steps to improve the work of our agency.”

    “He was an invisible child for a year and so we have to self correct and say we can’t have that happen and can’t have children falling through that large crack," VosWinkel said. 

    DCF officials said they have taken the following steps to improve their work: 

    • We conducted a thorough review of our involvement with the family;
    • We are implementing improvements to how we assess child risk and safety, including changes to the assessment tools themselves and enhanced staff training to increase the consistent and reliable use of the tools
    • We are strengthening visitation standards and requirements – especially when the family is preventing our access to the home and children.

    Matthew Tirado was described as "a mild-mannered child" who "enjoyed going to school, liked to use the microwave and cook his food, and enjoyed looking at books." He also liked to hand out Renters Guide in Hartford and delivering on the Oak Hill campus. 

    Matthew Tirado was a Hartford Public Schools student who attended Oak Hill School in Bristol. Hartford Public School District said the death of Matthew Tirado "is a tragedy for all of us in the Hartford community."  

    "The Hartford Public School District is compelled to take action to prevent similar incidents in the future. The District has been working closely with the Office of the Child Advocate and other agencies during the past year to revamp systems and protocols intended to protect students. Hartford Public Schools will continue to address the critical need to identify shortcomings in the safety net for our children, especially our children with disabilities," Hartford Public School District said in a statement on Tuesday. 

    The report states, “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.”

    In November 2016, Hartford Public Schools failed to contact DCF when Tirado withdrew Matthew’s sister from school despite having filed multiple child protection reports for both children.

    “A cross-departmental task-force has been convened to examine current processes for monitoring enrollment and attendance of outplaced students," Hartford Public Schools said. 

    Hartford Public Schools said they have reviewed the "current procedures for students whose parents have requested homeschooling for their children." They said they have implemented the following procedures to better protect the children:

    • Upon receiving notification that a parent seeks to homeschool their child, District staff will work with school staff to determine whether staff have concerns.
    • District staff will cross-check the student and family history with school-based referrals made to the Department of Children and Families and within the District’s iSight incident management system.
    • If concerns arise, the District point person will follow up with appropriate agencies, including making DCF referrals as necessary.
    • The District is developing a communication to parents of homeschooled children to be distributed twice a year, consistent with state law and administrative guidance, requesting that parents (1) indicate whether they are still homeschooling their child(ren) or if they have been enrolled in another district and (2) provide updates on their child(ren)’s portfolio and the instruction being provided at home.

    To read the full statement from the Hartford Public School District, click here

    The Connecticut Judicial Branch also released a statement on the report. 

    “We thank the Child Advocate for a careful and thorough analysis of this tragic case. She has made several recommendations that warrant serious consideration by the Judicial Branch, and we share her commitment to improving the safety net for children like Matthew Tirado,"  Hon. Bernadette Conway, who is a chief administrative judge for juvenile matters, said in a statement on Tuesday. 

    Katiria Tirado is still behind bars. She's due in court next week. 

    Copyright 2017 WFSB (Meredith Corporation). All rights reserved.