The woman who insisted Samantha Kematch's first baby be made a permanent ward of Child and Family Services was clear she feared for any future children the young woman might have.
"I said that Sam should never, ever parent a child. She was a red flag. I had that in my notes. I don't know how anyone could have missed it," said the social worker, who saved Kematch's infant son.
The recently retired woman, who does not want to be identified, said Saturday she doesn't understand why her urgent warnings were ignored. She feels terrible guilt Kematch went on to torture and kill Phoenix Sinclair, her second child.
"We (the worker and her supervisor) tried to keep track of her even after she aged out (of CFS care at 18)," she said. "We knew that someone should keep an eye on her."
The worker's story of her involvement with Kematch, her siblings and her newborn son is chilling. She says Kematch, 16 when she gave birth, nearly killed the baby before he was taken into care permanently.
When the worker first met them, Kematch and her brother were permanent wards of CFS. Their mother abandoned them on a Winnipeg street; their father later drunkenly fell down a flight of stairs and died. Kematch's older brother jumped off the Swan River water tower, killing himself.
The worker took charge of Kematch's file around 1996 after moving to Winnipeg to work for the Cree Nation CFS. Her clients were all permanent wards of the system. She had between 22 and 30 cases at a time and says Kematch was luckier than most.
"When I met her, an aunt was fostering her and her brother. There's people that loved her. She had family who took her into their homes. She had more than most of our kids."
But Kematch and her brother Mickey were runaways. Mickey would skip school. The worker would find him and take him back. She'd hunt down Kematch, using street contacts to find the girl. One time, she was staying in a boy's garage.
The worker enrolled her in a residential addictions-treatment program in St. Norbert. It didn't help. She continued to flee. Kematch was moved into an independent-living program at 16. She had her own apartment, money for groceries and safety. She was never there, the worker said. She met the 14-year-old father of her baby and hung out in his basement.
The worker told the boy's mom she couldn't harbour a CFS runaway; the mother said she wanted Kematch out of her house.
"We got information she's not eating, she's staying at his house all the time," the worker said.
She was astonished to learn the teen had given birth. Although another CFS worker had control of the file at the time, she rushed to the hospital. She scolded Kematch, telling her she could have lived at Villa Rosa during the pregnancy and had all the support she needed.
"It was heartbreaking," the worker said of the visit. "You'd see all these smiling faces, all these moms looking at their babies with big, smiling faces. There was nothing from Sam. There was no maternal instinct."
But those weren't grounds to apprehend a child, she said, no matter how much she might have liked to. By law, Kematch had to be given a chance to bond with her baby. She was moved to a complex for young moms and babies, a brand-new apartment with her own kitchen, bathroom and bedroom. She was briefly enthusiastic. The worker had doubts.
"I didn't trust her alone with the baby."
The worker's instincts were good. There was a baby clinic in the centre where the young moms learned about birth control, nutrition and other issues. Kematch didn't want to go. When her son was found to be very ill, she was forced to take him to the doctor.
"He had a temperature of 104. She didn't tell anyone."
The second time she was caught neglecting her baby, a worker heard a plaintive cry from the teen's room. She knocked and entered.
"She put the baby in the baby seat on the edge of the kitchen table. If he'd cried and kicked his feet, he would have fallen to the floor."
Kematch was down the hall visiting a friend. That's what she was doing the third time, when the baby was found lying in the bathtub on his back, water lapping above his ears. Kematch wasn't home. If he'd rolled over, the baby would have drowned, the worker said.
"I fought tooth and nail to make him a permanent ward."
The boy was moved into a foster home, where he remains. The worker smiles when she talks about him, clearly fond of the boy. She carries the guilt of saving one child but not the next, even though she wasn't working with Kematch at all when Phoenix was born.
She left an urgent note on Kematch's file, making it clear she should never have another child in her care.
The worker doesn't know why it wasn't heeded. And neither will the inquiry into the child's death. The social worker hasn't been called as a witness.