Almost two months after the death of a 2-year-old and the hospitalization of a 22-month-old in a DCF foster home in Auburn, the state released a report on the causes of death and injury as a case review on the foster mother. 

Ava Conway-Coxon and a 22-month-old identified only as Samara suffered a heat stroke while inside Kimberly Malpass’ home in Auburn on Aug. 15. The two were taken to hospital after Malpass was seen running out of her home screaming about the unresponsive children. They were taken to the hospital, where Ava was pronounced dead. 

Tests showed that Samara had high levels of salt and was dehydrated. She suffered from seizures, respiratory failure and a high fever. Authorities determined that both children had been exposed to high temperatures for an extended period of time. 

"Today's report unveils a series of failures within the department leading up to the devastating loss of a little girl and the near death of another little girl," Gov. Charlie Baker told reporters at a press conference held on Thursday. "The failures that are outlined by this report are unacceptable. The failures outlined in this must, and will be, promptly corrected to ensure the safety of other children in the care of the department."

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Responders filed a report with DCF.  At the time of the incident, there were four other children living in the house. A third child in DCF was taken to the hospital for evaluation, where officials found no signs of abuse, and authorities placed the child into another DCF foster home. DCF took emergency custody of the children and placed them with relatives the next day.

Samara was transferred to long-term rehabilitation on Sept. 3. 

"These findings reveal several instances where DCF staff failed to appropriately assess the foster mother and identify risks to the children in her care," DCF Spokeswoman Andrea Grossman said in an email to Metro Boston. "As a result, a corrective action plan will be implemented in conjunction with the reform efforts already underway as a result of the findings of last year’s CWLA quality review, the recently released report on the Hardwick case, and recently announced priorities between Local SEIU 509 and the Administration."

On Monday, Baker told the press that the number one goal of DCF was to "keep kids safe." SEIU Local 509 Chapter President Peter MacKinnon said that there would be many steps taken to improve DCF's ability to keep children and making sure social workers do not miss any warning signs of abuse and neglect. These steps include balancing caseworker workload to the standard of 18 cases to one social worker. SEIU 509 has called on legislators to act in order to counterbalance the overburdened caseworkers. 

“As a union of social workers and investigators, we go to work each day with a sole focus on keeping at-risk kids safe,” MacKinnon said in a press release. “We spend significant time with the children in our care, and we are deeply affected by tragedies like the case that has unfolded in Auburn. Our thoughts and prayers go out to the family, friends and loved ones affected by this tragic passing.”

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“Without exception, child protection workers believe in accountability. Whether systemic challenges or individual action, any factor that plays a role in a tragedy must be fully investigated and addressed accordingly,” MacKinnon said. “This case is no different, and we will continue to work with law enforcement and the Administration to ensure appropriate action is taken.”

The report showed that DCF did not follow proper protocol.

They did not properly approve Malpass’ entry into the DCF program, take into account her medical history which includes lupus, kidney failure, a Xanax prescription, and Social Security disability payments, the report said.  DCF didn't fully assess the safety of the home before issuing Malpass a license, nor were the Auburn Police contacted to inquire about the home. 

In March 2015, Malpass allowed her boyfriend to stay in the home, despite evidencet that he used drugs and had been recently charged with unarmed robbery.