Phoenix Sinclair’s death went undetected by welfare officials for months. Nine years later, an inquiry report into her case lays blame and spells out what needs to be done to fix a child welfare system in chaos.
The report says the system was overwhelmed and that social workers had too many cases and lacked training. But Commissioner Ted Hughes is clear that's not the reason Phoenix did not receive help.
Simply put, social workers and their supervisors did not do their jobs to protect the child.
“The child welfare system failed Phoenix Sinclair,” Kerri Irvin-Ross, Minister of Family Services, said at a press conference.“We deeply regret and are profoundly saddened by the loss of this child.”
That apology from the province followed the release of a 900-page inquiry report into Phoenix's case.
Inquiry Commissioner Ted Hughes said Phoenix was not protected because social workers and their bosses did not do their jobs.
"The social workers who testified at this inquiry wanted to do their best for the children and families they served, and that they wanted to protect children, but their actions and resulting failures so often did not reflect those good intentions,” he wrote in the report.
That is something the girl's former caregiver felt all along.“It had nothing to do with overworked, it had to do with them not following procedure,” said Kim Edwards.
The report calls Phoenix's mother, Samantha Keematch, cruel and negligent and Keematch's boyfriend, Karl McKay, violent, sadistic and dangerous. It also says that welfare officials were warned several times about ongoing abuse.
“There were so many opportunities that were missed, it's beyond comprehension,” said Edward’s lawyer George Derwin.
Just weeks before her death, one last complaint was made. The file was opened and closed within five days, signed off by management, even though no one from CFS actually laid eyes on Phoenix.
“All of those deficiencies were signed off on by supervisors,” Sherri Walsh, a commissioner with the inquiry.
The report has 62 recommendations to improve the system, including:
- Reducing caseloads for social workers to a maximum of 20
- Providing care for people beyond age 18, until age 25
- Replacing the children's advocate office with a better model
- Establish of a Manitoba College of Social Workers
The province promised to implement as many of the changes as necessary to increase oversight and safety.
“That we have a system where people, if a mistake is made, that they stand up and share that and we learn from that mistake,” Irvin-Ross said.
But if those mistakes continue, there will be no discipline or action taken against anyone. That has Kim Edwards concerned. She says you can put in new rules, but what if no one follows them?
The province did not say how much it might cost to implement the recommendations. The province said half of the recommendations have or are being put into practice
An implementation team, at a cost of an additional $350,000 will probe the remaining 31 suggestions to see which ones are workable.
- With a report by Jeff Keele
