Phoenix Sinclair was just over one year old in the summer of 2001 and may have already been falling through the cracks of Manitoba's child welfare system.

The Phoenix Sinclair Inquiry continued Thursday with testimony from Lorna Hanson, a child and family services supervisor.

The inquiry heard that a child welfare worker assigned to Phoenix's case failed for weeks to act on multiple tips that said Phoenix and her sister Echo could be in danger. Weeks later, Phoenix’s sister died of a respiratory infection.

The inquiry is looking into the circumstances surrounding Phoenix’s life and death. Phoenix was in and out of foster care throughout her life before being killed at age five on the Fisher River Cree Nation, north of Winnipeg, in 2005. Phoenix's mother, Samantha Kematch, and stepfather, Karl McKay, were found guilty in 2008 of first-degree murder in her death.

Phoenix turned one year old in April 2001, and a short while later, her younger sister Echo was born.

Echo was placed with her and Phoenix’s parents – Kematch and Steve Sinclair -- when she was born.

Despite Phoenix and another child being removed from Kematch’s care in the previous three years, a hospital intake worker decided the two were fit to care for the third child, a baby girl. The pair was sent home, with a CFS worker in their community asked to follow up.

By June 2001, the inquiry heard that it was apparent there were problems.

Tips went unanswered for weeks

An email, sent in mid June 2001 by a child welfare worker, detailed issues with violence in the home.

Phoenix's CFS worker at the time, Delores Chief-Abigosis, failed to follow up on the email.

Lorna Hanson, Chief-Abigosis’ supervisor at the time, testified Thursday that the email was never passed on to her, and if it had been, she would’ve sent a child welfare worker out immediately.

Within days of the initial email, two more tips detailing issues of violence and alcohol in the home came in. Still, her case file showed no one went out to the home to check on her or her sister Echo.

Around that time, Steve himself contacted CFS, telling a child welfare worker his daughter Echo had been taken by police and given to Kematch. Sinclair appealed to CFS for help, saying he was worried about her wellbeing.

Finally, on June 29, 2001, two weeks after the first tip was sent to CFS and just one day after police responded to a domestic violence call at Steve’s home, a CFS worker was directed to check on the two children but didn’t show up until days later on July 4.

There, the agent found Steve had been caring for the two girls, and Kematch had left.

The inquiry was told It took another two days for Chief-Abigosis, Phoenix’s child welfare worker, to show up herself.

Supervisor said she was unaware of what was happening

Hanson testified Thursday if she had been aware of the multiple requests, she would've acted immediately to ensure the children were safe.

Hanson also testified that the after-hours CFS unit she coordinated had such heavy caseloads that they didn't have the "capacity to respond" to the issues they needed to.

Over the next two weeks, Echo was returned to Steve and workers met with him, noting he was applying for full custody of his children and would begin attending parenting classes.

A short time later though, Echo died in Steve’s home.

Workers didn't know where Phoenix would be at age one

On July 15, 2001, Phoenix's sister Echo died of complications from pneumonia. The medical examiner said there was no indication that Echo had been abused.

Hanson admitted that she did not remember Echo’s passing and that it wasn’t uncommon in her field. She said, “Sadly I can’t recall the death of this infant. Unfortunately in our work, death -- tragedy -- is an everyday occurrence.”

At the time of Echo’s death, Phoenix was staying with Steve's sister Jenny. Hanson admitted CFS workers didn't know or ask how long Phoenix would stay with Jenny or when she would return to the care of Steve.

Commission counsel asked Hanson why the agency didn't know the long-term plans for Phoenix's care.

Hanson said because the death was not deemed a homicide, the risk to Phoenix was significantly reduced. She added, "There seemed to be appropriate supports in place."