A state audit released Thursday found that the Massachusetts' child welfare agency failed to report rapes, abuse and serious injuries committed against children under its care.

The report, released by State Auditor Suzanne Bump, focused on 19 serious incidents that were not reported where children in foster care and other state-supervised settings were harmed.

The audit said from 2014 to 2015, the Department of Children and Families was unaware of 260 incidents of what appeared to be serious bodily injury to children in its care.

The incidents included a 15-year-old with brain damage from a firearm injury, a 1-year-old with first-and second-degree burns, and a 12-year-old with multiple head contusions that a doctor determined were the result of an assault.

"The children entrusted into DCF care are among the most vulnerable residents of the Commonwealth," Bump said in a statement. "This audit found that despite reforms, victimization of children in DCF’s care continues to occur unnoticed by the agency."



The audit also found that the DCF was not categorizing incidents involving sexual abuse as critical incidents. Therefore, these incidents were not reported to the Office of the Child Advocate, which is charged with ensuring that children in state care receive safe and effective services.

Bump's office found 118 incidents of sexual abuse of a child in DCF care that were not reported.

These incidents included two male employees at different DCF-contracted residential facilities who sexually abused three girls each; a 10-year-old who was raped by his father; a 4-year-old who was sexually abused by her mother; and a 17-year-old who was gang-raped by five assailants. In one case, a male who had sexually abused one child abused the child’s sibling less than one year later.

"When there are allegations of sexual abuse, the Department urgently addresses a child’s safety and emotional distress through its investigations process," the DCF said in a statement to NBC Boston.



"How can the agency not consider sexual abuse a serious injury to a child? It defies logic," Bump said.

The audit recommends that in the future, DCF use MassHealth data to help identify incidents of serious bodily injury to children in its care. Children in DCF care who have been removed from their homes are enrolled in MassHealth, and DCF has access to claims data for these children but is not currently using this information to identify serious medical incidents.

"The work of DCF is incredibly difficult and extremely important. This is why it is so critical that the agency uses all of the tools at its disposal, such as MassHealth claims data, to identify and investigate physical harm to children in its care," Bump said.

DCF has initiated "significant system-wide reforms" and new policies in the two years since the audit period. And it is also taking several other steps in the wake of the audit's findings, including:



Centralizing its reporting of critical incidents in which children in its care are involved;

Working with the Office of the Child Advocate to ensure expectations are met for "critical incident reporting" and reviewing the critical incidents cited in the audit.

Updating its procedures for referring incidents of abuse, neglect, and/or sexual abuse of children to district attorneys’ offices for investigation; and

Recording child-on-child injuries in case files.