Massachusetts agencies and courts failed to consider what was best for 4-year-old Harmony Montgomery when she was put into her father’s care in 2019, according to a new report out Wednesday.

“The system failed Harmony ... at every decision point,” Maria Mossaides, director of the Office of the Child Advocate, said at a press conference Wednesday morning. "It wasn’t just one decision. It was a series of decisions that did not place her at the center and therefore made poor decisions about the risk that she was going to be facing.”

News late last year that the young girl had not been seen in two years provoked a national outcry. She was believed to be living with her father, Adam Montgomery, in Manchester, N.H. Many demanded to know how a vulnerable child could slip through the cracks. Massachusetts courts, in particular, took heavy criticism from top-level officials like the New Hampshire governor for putting Harmony in the care of her father in the first place.

Harmony was last seen in October 2019, just months after her father was granted full custody. The Office of the Child Advocate report found that prior to the February 2019 court custody decision, Adam Montgomery had spent less than 40 hours with his daughter during her entire life, in visits supervised by the Department for Children and Families.

A months-long OCA investigation culminated in a 101-page report released Wednesday morning, which details how Massachusetts agencies handled — and failed to handle — the case of Harmony Montgomery. The report cites multiple legal failings but mostly points to failures to coordinate across state lines and Harmony’s attorney’s failure to assert what was best for her in her custody case.

In the end, Mossaides said, the court weighed parental rights over what was in Harmony’s best interest.

“The what-ifs don’t count here,” she said. “No one focused on Harmony, this beautiful little girl, and what she needed.”

The child advocate’s office ultimately recommended that Massachusetts reevaluate how children are represented in custody cases. But advocates say overhauling that system would likely do more harm than good.

“While it seems there may have been oversights in this case, deficiencies, kind of a whole-scale reform or reversion to a completely different model is probably not the right answer,” said Allison Green, the legal director for the nonprofit group National Association of Counsel for Children, which advocates for better representation for children in court. “Generally speaking, we endorse the model Massachusetts currently uses.”

“The trend is towards Massachusetts' model, not away from it,” she added. Massachusetts’ attorneys are directed to represent the children’s express or stated interests in the courtroom, which Green says is increasingly being used instead of having attorneys push for both what the child wants and what the attorney finds is in the child’s best interest.

Green pushed for a greater investment to investigate each case rather than redistributing what are often already-thin resources to set up an entirely new system.

Seven-Year-Old NH Girl Missing Since 2019
Manchester - January 4: An electronic billboard above a building on Main Street in Downtown Manchester, NH shows a photo and information on missing 7-year-old Harmony Montgomery on Jan. 4, 2022. (Photo by John Tlumacki/The Boston Globe via Getty Images)
Boston Globe/Boston Globe via Getty Images Boston Globe

Others praised the deep investigation of what went wrong in Harmony’s case.

“The Massachusetts report is robust, transparent, and we appreciate their hard work,” New Hampshire Gov. Chris Sununu told GBH News in a statement. “While this 101-page report focuses on Harmony within the Massachusetts system, there is without a doubt a lot New Hampshire can learn from and improve upon. These are challenges and issues facing all of New England — and we have a shared commitment across the region to get it right.”

In March, Massachusetts started working with the other New England states to figure out improvements to cross-state custody cases.

Blair and Johnathan Miller, who adopted Harmony's half brother Jamison, told GBH News that they are pushing for two new policies to make sure that cases like Harmony’s don’t happen again. The pair want parents to be more rigorously evaluated with home visits in such custody cases, as they say they were when they adopted their three boys. Siblings should also be given more weight, as the Millers say they expressed interest in adopting Harmony but weren’t given the opportunity to.

“We often daydream what it would look like if Harmony and Jamison were able to stay together,” the couple wrote in a joint statement. “We are angry and saddened. Our five-year-old son will one day know that his sister was not protected.”

Mossaides noted that “we do not know Harmony Montgomery's ultimate fate, and unfortunately, we may never.”

But it is clear, she said, that the child protection system failed her. “We owe it to her to make the changes necessary to allow our system to do better in the future.”