A culture of non-compliance.
After sitting through 91 days of hearings, examining more than 100 witnesses and reviewing tens of thousands of pages of documents, former judge Ted Hughes determined the child-welfare system's inability to "act on what it knew" and comply with existing policies and procedures left Phoenix Sinclair completely vulnerable.
This is not a case where any one person can be directly blamed for allowing Phoenix -- a chronically neglected and physically abused five-year-old -- to fall into the hands of two dysfunctional, substance-abusing, violent adults. Hughes was not permitted to assign direct blame.
Instead, Hughes indicted the entire child-welfare system in Manitoba, including its political masters, for creating a culture that paved the way to tiny Phoenix Sinclair's death.
The realities of child welfare are painstakingly detailed in Hughes' report. The family dysfunction that puts children at risk, Hughes wrote, is the result of many factors that are beyond the scope of social workers and bureaucrats. Hughes acknowledged there were also "organizational challenges" that contributed to the stress on the system, including too few social workers and resources to support families.
Remarkably, Hughes does not accept these organizational challenges are a sufficient excuse for what happened. Hughes instead concluded the resources, policies and procedures in place at the time Phoenix was in and out of the child-welfare system were sufficient to offer her protection.
Instead, Hughes blamed what can be called a culture of non-compliance, where social workers and supervisors could see the threat, but were nonetheless unable to protect the child.
Hughes repeatedly refers to the events of March 5, 2005, when Winnipeg Child and Family Services received a tip Phoenix was being abused and locked in a bedroom. An investigation was opened, however no one from CFS actually "laid eyes" on Phoenix to verify the allegations. After five days of shuffling papers, a supervisor closed the investigation.
Phoenix was murdered three months later.
Hughes found the decision to close that investigation troubling, given the information the agency had about the family's chronic dysfunction and past history of abuse and neglect. "I believe that the Child and Family Services workers who testified at this inquiry wanted to do their best for the children and families they served," Hughes wrote. "I believe that they wanted to protect children. However, their actions and resulting failures so often did not reflect those good intentions."
Hughes does not attempt to explain the origin of this culture. This is not, however, the first time this phenomenon has been examined in Manitoba.
There are numerous examples of public servants failing in the commission of their duties because they feel ignored, disrespected or misunderstood.
Those who toil in the child-welfare system do so with the burden of knowing they have one of the most important but least respected jobs in all of government services.
Almost no one in the general public really understands the horrors those within the system contend with. When average citizens stop to contemplate child welfare, if they do so at all, it is to lament the expenditure of taxpayer money being spent trying to help people who will not help themselves.
There is the added burden of knowing the contempt many citizens exhibit toward dysfunctional families can translate into a lack of respect for the people who work within that system.
In this scenario, the public servants begin to lament the fact they are overworked, underpaid and generally misunderstood. After a while, these factors combine to create a culture where public servants fall prey to despondency and self-pity. Ultimately, otherwise sensible and intelligent people begin to accept failure as an inevitable, perhaps inescapable, outcome.
Which brings us to the issue of political oversight and accountability.
Ministers of the Crown cannot be expected to take responsibility for each and every failure in their departments. Family Services Minister Kerri Irvin-Ross certainly showed leadership in apologizing, without reservation, for the failure to protect Phoenix.
However, the failure here is more complex than Irvin-Ross is willing to admit right now. While political masters cannot control service delivery on a case-by-case basis, they certainly must be diligent in ensuring a dangerous culture of non-compliance doesn't take hold in their departments.
The NDP government, which has some natural political affinity for the social work community, failed utterly in its oversight of Child and Family Services.
There is simply no acceptable excuse for allowing front-line social workers to descend into a despondent, white-flag-waving pity party that failed Phoenix Sinclair so tragically.
In a more perfect world, these are the stories that would topple governments and force real accountability. In the real world, however, the apathy and contempt most hold for the child-welfare system will, ironically, provide political coverage for this government.
And the tragedy continues.