WINNIPEG -- Phoenix Sinclair began to fall through the cracks of Manitoba's child-welfare system mere months after she was born to parents with a history of violence and substance abuse and five years before she was beaten to death.

Social workers failed to monitor the family for months at a time, and failed to investigate after the girl was brought to hospital with an infection from an object that had been embedded in her nose for three months, according to a document obtained by The Canadian Press.

The document is a 2006 review of Phoenix's death by then-provincial children's advocate, Billie Schibler, and Andrew Koster, head of a children's aid society in Ontario. The report has been kept secret, but some portions are now being discussed at a public inquiry into the case.

"From October 2000 to the last contact with this family, actual service was almost non-existent," the review says.

"There was no recorded contact between October 2000 and February 2001, even though the service agreement signed on Sept. 5, 2000, states 'meeting with the worker on a regular basis."'

The review notes other long periods of time when social workers had no direct contact with the family in 2002 and 2003. Sections of the review that deal with the following two years leading up to Phoenix's death in 2005 remain confidential.

The five-year-old girl was killed in June 2005 by her mother, Samantha Kematch, and her mother's common-law husband, Karl McKay. The couple were convicted of first-degree murder. Evidence at their trial showed they had abused and neglected the girl, sometimes forcing her to eat her own vomit and shooting her with a BB gun.

Phoenix died not long after she was removed from a foster care home and returned to Kematch. Her death went undetected for nine months until a relative phoned police and the child's body was discovered in a makeshift grave near a dump on the Fisher River reserve.

The inquiry, which has heard five days of testimony so far, is examining how Phoenix was failed by child welfare despite numerous warning signs from the moment she was born in April 2000.

Her mother and biological father, Steve Sinclair, had both been in foster care and had a long list of troubles.

Kematch had stolen cars, had hung out with gang members and had run away from foster homes. Months after she turned 18 and became too old to fall under child welfare, she gave birth to Phoenix.

Sinclair was aggressive and addicted to alcohol. A review of his case, done as he turned 18, warned that he should not be given care of children.

"Steven remains to be a highly disturbed individual who should not be left in charge of dependent children," the review states.

Kematch was on welfare and had already had another child taken from her two years earlier. The inquiry heard from a social worker that she and Sinclair were uninterested in being parents and didn't have a crib, clothes or a car seat for the baby even as they went to the hospital for her birth.

Despite all that, social workers tried to reunite the family after taking Phoenix from the couple days after her birth. They developed a plan which required Kematch and Sinclair to take parenting classes, visit Phoenix weekly and have an in-home support worker. Kematch was also to undergo a psychological assessment.

By Sept. 5, 2000, the girl was back with her parents on the condition that they have regular visits from social workers to ensure that she was being properly cared for.

The review obtained by The Canadian Press says that didn't happen.

Starting in October, there was no recorded contact with the family for four months. A social worker did visit the family in February 2001, but that was followed by more inaction.

"There was no direct contact between Feb. 9, 2001, and July 4, 2001, even though the worker stated in a Feb. 9, 2001, meeting 'it is necessary to meet as they are an open file and we need to monitor and assess their family situation,"' the review states.

A social worker did meet with Sinclair on July 6, 2001, and committed to meet with him weekly. That plan fell by the wayside as "there appears to be no direct contact between July 6, 2001 and March 27, 2002 ... although two attempts were made," the review reads.

On February 26, 2003, social workers were called by the Children's Hospital in Winnipeg. Phoenix had an object in her nose -- Kematch and McKay's murder trial was told it was Styrofoam. She had recently been handed to a family friend for care.

According to the review, the object had been in the young girl's nose for three months and an infection had developed.

"Allowing a child to have a foreign object embedded in her nose for three months without medical attention is clearly neglectful, and a thorough investigation of Phoenix's living situation should have been conducted at that time, with or without Steven's consent," the review says.

"It must be noted that the intake worker did make numerous attempts to connect with Steven during March, April and May 2003 but was not successful in finding him home."

The review's details have not been dealt with specifically at the inquiry to this point. However, social workers have complained about high workloads. One supervisor testified that caseloads in Winnipeg's North End neighbourhood were triple the amount recommended by a U.S. industry group.

Phoenix spent most of her life in foster care, but was returned to Kematch and/or Sinclair on a few occasions. She was given to Kematch a final time in 2004 and social workers closed her file. Months later, she was killed after enduring horrific abuse.

The 2006 review has been kept under wraps due to the Child and Family Services Act, which forbids the release of an individual's information. That ban had been lifted by the start of the inquiry, but inquiry lawyers have decided to release pieces of the report only as they are brought up in testimony.

The portion obtained by The Canadian Press was discussed briefly at the inquiry Thursday and is due to be uploaded to the commission's website Monday along with other exhibits. Commission staff agreed to provide a copy to The Canadian Press on Friday.

The inquiry is still in its early stages. It has yet to delve into why child-welfare workers removed Phoenix from a foster home and gave her back to Kematch in 2004 and what, if any, monitoring followed. Kematch and McKay's murder trial was told a social worker went to visit the family in 2005, was told Phoenix was sleeping and left without seeing her.