As Phoenix Sinclair was shuffled from crisis to crisis, in and out of care, it's almost surprising she lived to the age of five.
The inquiry into her death Tuesday heard how the little girl bounced from one unsuitable environment to another -- from a weekend drinking party with gang members at her father's place, to her time spent with her absent, boozing mother and crack-smoking grandmother, to living in a former "place of safety" where the occupants failed to notify anyone they had Phoenix in their care.
When Winnipeg Child and Family Services located Phoenix at the "place of safety" in January 2004, the agency decided to leave her there and close the file, the inquiry heard.
The inquiry is attempting to get to the bottom of the tragic case of Phoenix and how the child welfare system failed her.
It is now in its fifth week and could run until May.
Lisa Conlin was the intake worker assigned the case when Phoenix was found at the home of Kim Edwards and Rohan Stephenson in January 2004. She closed the file and sent the couple a letter on Feb. 13, 2004, saying they shouldn't let Phoenix be returned to her father.
It did not specify they shouldn't let Phoenix be returned to her mother.
"That was an oversight on my part," Conlin testified at the inquiry Tuesday.
Both the little girl's father, Steve Sinclair, and her mother, Samantha Kematch, would put Phoenix at risk and both had the legal right to take Phoenix at any time, Conlin acknowledged.
Edwards and Stephenson had been a former "place of safety" approved by CFS, but they had no legal custody of the little girl.
In May 2004, CFS learned Kematch wanted Phoenix. In 2005, she murdered her five-year-old daughter.
Phoenix's death wasn't discovered until 2006.
CFS had closed the file on Kematch in 2001 after she left Phoenix with Steve Sinclair.
Conlin said Phoenix was in a safe place with Edwards and Stephenson. The intake worker focused on Steve Sinclair because he was the one who was supposed to care for Phoenix. She knew Kematch wasn't out of the picture, though.
On Jan. 15, 2004, CFS got a call that Phoenix was with Kematch and was at risk. The caller said Kematch took a then-three-year-old Phoenix from Sinclair's home while he left his daughter alone in mid-November 2003. Phoenix had been returned to him in October after she was apprehended by CFS and a temporary order placed her in care for three months. She was taken from her dad in June 2003 during a weekend drinking party when there was no food in the home but plenty of gang members, the inquiry heard earlier. When the three-month court order expired, Sinclair got Phoenix back -- no questions asked.
The caller in January 2004 accused Kematch of leaving the toddler to go drinking and in the care of her own mother who smoked "rock". Conlin followed up and found that Phoenix had been taken from Kematch on Jan. 2, 2004, by Edwards and Stephenson. They hadn't notified CFS that they had Phoenix for nearly three weeks or report what kind of situation they had rescued her from, Conlin said.
Nor did they mention they had broken up and Edwards was no longer living in the home, Conlin said.
As far as the intake worker knew, the home was still a place of safety, she said.
Stephenson told her they were happy to care for Phoenix and didn't need or want any help from CFS.
Conlin didn't follow up with the couple or speak to Edwards. Her supervisor advised her to contact the last supervisor of the file, Heather Edinborough, for advice. Edinborough, who testified at the inquiry last week, recommended leaving Phoenix with Edwards and Stephenson and transferring the file back to family services.
Conlin said she decided to close the file rather that transfer it to a family services social worker for followup.
"The main reason was we had an agreement with Steve (Sinclair), the Stephensons and myself... there was no immediate crisis in the actual home she was in."