In 2006, Mel Holley read all the Manitoba child death reports on file. The province's acting ombudsman learned the appalling variety of ways children in Manitoba have been abused, murdered or taken their own lives. There were awful themes in the reports, problems that continued to be present across the years.
"Every child, I read about," he said during a telephone interview Tuesday afternoon. Patterns emerged from the files.
"It may be addiction or suicide or federal provincial cost-sharing. We've had these problems forever in the child welfare system. Are we fixing them? Well, no."
Holley released his followup report to the 2006 report on child welfare services after the death of a child Tuesday. In it, he said there have historically been workload and inadequate resource issues raised by workers in the child welfare system. Anyone with an eye on the Phoenix Sinclair inquiry knows these concerns continue.
Holley was refreshingly frank when he talked about the report and his expectations of change.
"I want people to keep drilling down until you understand why children continue to die (while in the care of the child welfare system)."
There were 161 child deaths in Manitoba in 2011-12. The majority occurred naturally. Special Investigation Reviews (SIRs) are done if the child or its family had a file with CFS or within the year prior to the child's death. They replace the former Section 10 reports.
Of those 161 deaths, 61 were eligible for review and 12 were children who were under CFS care.
In 2011, the Child Protection Branch reported there were 19,714 families, unmarried adolescent parents and children receiving out-of-home care, such as foster care.
The Phoenix Sinclair commission has repeatedly heard that front-line workers didn't know which set of standards they were supposed to follow. They've also said they wish reviews conducted after a child's death were shared with the employees whose jobs were reviewed,
Holley doesn't know why those reports aren't shared with employees because that's not part of his mandate. He suggested they aren't shared with the public due to privacy concerns.
"Is there a value to it? Yes. Is there a danger to it? Yes."
Holley said information in the reports may be one-sided and shouldn't be widely disseminated.
He is not attending the Phoenix Sinclair inquiry because it would be too depressing, he said. He remains troubled by what he read in those death files.
He said progress has been made in the province's ability to review and report on the deaths of children in care.
"Our child welfare system is a complex network of agencies and services that provides a variety of services and supports to almost 20,000 families, single adolescent parents and children in Manitoba," said Holley. "Resolving larger, systemic issues is essential to ensuring that the child welfare system in Manitoba continues to improve and provide children, families and communities in the province with better services.
"The child death review process enables the OCA and the ombudsman's office to review, monitor and report publicly on issues that span the province and relate to child welfare as a whole."
But in 2011, and since, more than 347 recommendations have been made to enhance the safety and well-being of children and prevent deaths in similar circumstances in the future, Holley said in his review of the Office of the Child Advocate's work.
Holley said holding inquiries is one thing. Having takeaway lessons is another.
"Say there are significant suicides among kids in care. How are we going to address that?"
His report reveals what child welfare insiders have long known: Northern and remote communities sometimes lack Internet service and cellphone networks. They can't access the province's central information system. As well, the report says some regions have fewer professional and specialized supports such as psychiatrists.
So how do you level the playing field? "I don't know. We are trying to make this stuff an issue," says the frank Holley. "If you don't think about these things, we're going to keep having Phoenix Sinclair inquiries year after year."
He compares the work in getting child welfare working properly to ending poverty. No one has done it yet but they don't stop trying.