AUTHORITIES knew there were serious problems in Tracia Owen's family before she was born.
In March 1991, a nurse at the Little Grand Rapids nursing station wrote a letter to the provincial government, pleading for intervention. She detailed some of the family's many issues, alcohol abuse and domestic violence among them.
She said clearly there was the possibility of a tragic outcome for this family. That nurse seems prescient today.
Tracia Owen hanged herself in the summer of 2005.
The inquest report into Owen's life and death, released Wednesday, is blunt about the merit of the nurse's warning:
"This was not a case of 20/20 hindsight. The warning was there from the beginning, making it exceptionally tragic," Judge John Guy wrote.
Owen had a lifelong relationship with Child and Family Services. She was first seized from her parents when she was two months old. Over the course of her short life, she would be boomeranged back and forth 17 or 18 times.
Sometimes she stayed with her grandparents, sometimes with other members of her extended family. Time after time, she'd be sent home.
Then her parents would start drinking again or dad would beat up mom and the little girl would be moved out.
Over and over and over again.
When Tracia died in a West End Winnipeg garage, she had been sucked into a spiral of drugs and prostitution. She was a chronic runaway, still under the care of CFS.
Ironically, she was probably in the best placement of her life, a facility that could have helped her deal with her sorry life and its predictable consequences.
Many of the tragic elements of this girl's life are familiar to anyone with a passing interest in Manitoba's child welfare system. Her inquest details incomplete files, untrained workers, a desperate shortage of resources and an almost crippling lack of planning for her future.
Look to the dead Gage Guimond and Phoenix Sinclair for other examples of kids who were trapped in the system, sent off to live with relatives who can't care for them or simply not monitored properly because there are too many children in need and not enough resources.
One of the central flaws in Tracia's care appears to have been CFS's insistence on keeping children with their families, no matter how dangerous or dysfunctional those families may be.
It didn't take a genius to realize, fairly quickly, that Tracia's parents were not capable of looking after her or her siblings.
In Judge Guy's report, Children's Advocate Billie Schibler is quoted:
"Recognizing that children need to be in a safe environment, I think it is really important that while the whole philosophy in child welfare supports or should support that the primary focus should be on preservation of families, at no point should a child's safety and well-being be compromised in order to have that happen."
Tracia's safety and well-being were clearly compromised.
Here's what else the inquest report says:
"... while the Agency was waiting for many years for the parents of Tracia Owen to solve their personal problems, Tracia herself was sniffing, needing treatment, acting threatening, suicidal... Contributing to this spiral was the lack of long-term planning, proper assessment, insufficient documentation, lack of accountability to standards, lack of oversight."
And then this damning conclusion:
"Somewhere, opportunity for the parents should have been replaced by opportunity for Tracia."
Wiser words may never have been spoken.
Tracia Owen was never "lost," not in the same way Phoenix Sinclair was tragically misplaced by CFS when she was killed, buried and dead for months before anyone noticed. Tracia wasn't murdered as a toddler, like Gage Guimond.
But she was damned by a system that did not do what it is supposed to do.
They didn't put the child first.
Yesterday, Elsie Flette, CEO of Southern Manitoba Child and Family Services Authority, told me Tracia had been desperate to go home. She had called her family constantly, had run away from her group homes and wanted, more than anything, to go back to Little Grand Rapids.
No doubt she did. She was looking for the very thing that was denied to her over and over again.
She wanted a safe and loving home. It never occurred to her, because CFS kept sending her back, that her parents were never going to provide it.
The inquest into her suicide concludes: "Although Tracia Owen died August 2005, a review of the testimony suggests the foundation for her tragic death was laid many years before."
That nurse knew before the baby was even born.
Why did an inquest have to be held before everyone else caught on?