The Manitoba Advocate for Children and Youth has just released her report into the death of Tina Fontaine. 

The 15-year-old's body was found in the Red River in August 2014 wrapped in a duvet weighed down with rocks-- her death sparked outrage and ignited calls for the National Inquiry into Missing and Murdered Indigenous Women and Girls.

The man charged in her death was acquitted of second degree murder in February 2018.

Prior to her death Fontaine visited Winnipeg in July 2014 to see her mother.

The release of the report took place this morning in Fontaine's home community of Sagkeeng First Nation, Man., and delves into the public services provided to Fontaine during her life.

“My role is not to blame anyone individually for why Tina died,” said Manitoba advocate Daphne Penrose in her executive summary. “My role is to formally review child-serving systems and to hold them accountable for the ways in which families receive public services in Manitoba.”

“Finding fault for how and why Tina died is not what I am empowered to do.”

The report notes Fontaine came into contact with victim services in the wake of her father's death, the education system, mental health services and Child and Family Services. 

The investigation found at times, particularly in the final months of her life, those services failed to provide the support and interventions Fontaine desperately needed.

“The event that changed Tina’s life was the violent and sudden death of her father,” said Penrose. “This was the experience that many people who knew Tina look to when they think back to when things started to change for her.”

The report found victim services didn’t follow through with providing counselling sessions to Fontaine after her father’s death and never met directly with her in the two and a half years in which they were involved with her family.

It found chronic absenteeism in school increased after her father died and there was no coordinated plan to help Fontaine at a time when it was evident her struggles were growing.

“Following a suspension in April 2014, Tina did not return to school,” the report stated. 

Penrose’s report found Fontaine had acute mental health needs following her father’s death but never received counselling or other cultural healing.

“Tina developed acute addictions in her final months of life and used many different drugs and alcohol but was unable to find the help she needed that would support her to address her underlying pain.”

The investigation also looked into Fontaine’s involvement with Child and Family Services which she came into contact with when she was young and then again in the months before her death. 

“Our concerns with CFS following our investigation include the ways in which the family unit was allowed to fracture and split, the need for public systems to recognize Indigenous customary care arrangements, the barriers that are built when multiple service providers argue over jurisdiction, and the desperate need that exists in Manitoba for safe and secure placement resources when youth are at imminent risk of harm and death.”

"Every system failed her," Tina's great-aunt Thelma Favel said after Penrose delivered the report to her before it was officially released.

The report calls on Manitoba Education to review the use of out-of-school suspension, Manitoba Health to expedite a clear implementation plan to address child and youth recommendations in the Virgo report and Manitoba Justice to evaluate services provided through victim support.

The report also contains a recommendation for Child and Family Services to develop a plan to determine how safe and secure treatment facilities can be introduced in Manitoba and calls on the families department to create a new protocol to ensure response plans for all missing youth including sexually exploited youth, in particular those who are at risk of imminent harm.

Favel said she is happy with the recommendations and family members hope the report will make sure no other children fall through the cracks.

Premier Brian Pallister says his government is looking forward to reading the recommendations and acting on them.

He notes that they're well thought out.

"This is an issue all Manitobans need to get behind, that we failed our children in the past is indisputable,” said Pallister

 - With files from Steve Lambert and Kelly Geraldine Malone at The Canadian Press and CTV's Kayla Rosen and Jeff Keele.

Read the full report: