From the moment she was born, social workers knew Phoenix Sinclair was in danger and did little about it.
And, though much has been done to overhaul Manitoba's child-welfare system since the little girl's murder, much remains that needs fixing.
In a 900-page report released Friday, inquiry commissioner Ted Hughes dissected the failures of front-line social workers and the system as a whole -- the gaps in training, protocols and paperwork that allowed the five-year-old to suffer months of violence at the hands of her mother and stepfather.
Phoenix's death in 2005 became emblematic of a child-welfare system mired in a crisis caused by overwork, profound mistrust and misplaced priorities. Phoenix's death, when her body was discovered in a trash dump on the Fisher River First Nation, highlighted the dramatic over-representation of aboriginal children in care and the root causes of family failures, such as poverty, generations of abuse and addictions. It prompted a half-dozen reviews and nearly 300 recommendations to reform the system that failed her.
More than 60 recommendations were added to the to-do list Friday following Hughes' two-year public inquiry into Phoenix's death. Hughes pinpointed problems with caseloads, computer software and oversight. He called on the province to abolish the office of the Children's Advocate and replace it with a much more powerful independent office with the ability to keep close check on the child-welfare system. He also recommended a national discussion of aboriginal child welfare among the country's premiers.
Hughes laid significant blame for Phoenix's death on front-line workers and supervisors who knew from the moment she was born her mother was indifferent, her father struggled with his own demons and the child was at significant risk. Hughes found child-welfare workers got tips or information at least 13 times that Phoenix was in danger or neglected. More than 25 child-welfare staffers were involved with the family but none knew she was missing for months except the boy who saw her die.
"Deficiencies in the delivery of services to Phoenix did not result from a lack of understanding of policies, procedures and provincial standards, or from confusion about which standards applied. Rather, they resulted from a lack of compliance with existing policies and best practice," Hughes wrote. "Even when the agency asked the right questions and did an appropriate assessment, it failed to follow through on providing the services that it had identified as necessary."
On Friday, for the first time and at Hughes' urging, the provincial government apologized for Phoenix's death.
"We know now how a little girl became invisible, and we have already implemented changes to prevent other children from disappearing like she did," Family Services Minister Kerri Irvin-Ross said.
Since Phoenix's death, Manitoba's child-welfare system has seen dramatic bureaucratic changes, a doubling of funding and a much more aggressive approach to child protection that's boosted the number of kids in care to nearly 10,000.
Hughes said the system is on the right track but has "more distance to cover."
'We know now how a little girl became invisible, and we have already implemented changes to prevent other children from disappearing like she did' -- Family Services Minister Kerri Irvin-Ross
The province says work on 31 recommendations is already underway and an implementation task force has been set up to study the rest and report back to the minister in September.
Irvin-Ross announced an initiative Hughes did not recommend -- the creation of a critical-incident reporting system like the one in health care. But when a patient dies or is injured in a hospital, critical-incident reports are typically kept secret by government, much like child-death investigations are kept secret by child-welfare authorities, making public accountability problematic.
Asked whether she would make child-welfare critical-incident reports public, Irvin-Ross said she would consider it.
The minister was also asked repeatedly whether any social workers were disciplined after Phoenix's death, or whether any would be if they failed to follow proper procedures in the future.
"I can only tell you that we're going to reinforce the importance of following procedures (in) protecting children... " the minister said.
Progressive Conservative family services critic Ian Wishart said his party agrees with a report recommendation to establish a Manitoba College of Social Workers to license social workers and discipline those who fail to follow established professional standards. He said this approach has worked well in other areas, such as with physicians. "That's the standard that society has come to expect, and I think that's what we should be expecting here," he said.
Missing from the report was a significant discussion of devolution, the massive and messy process of transferring control of aboriginal child-welfare cases to aboriginal-run agencies.
Assembly of Manitoba Chiefs Grand Chief Derek Nepinak said there was little in the report that explored how aboriginal people can build a system more fully based on their cultural traditions.
"I think the province purchased time with the inquiry. They purchased time so they can sit back and brainstorm and arrive at conclusions."
Nepinak said there has been no contact between the province and the AMC on Hughes' report and its recommendations. "They have made great efforts to keep our leadership out of the decision-making infrastructure. This great bureaucracy that has been created has not made room for us."
-- with files from Bruce Owen
Implode and reform the child advocate's office
A Manitoba representative for children and youth should be created and given the same independent watchdog role afforded to the provincial ombudsman and auditor general. This would replace the children's advocate's office and offer a much broader, more aggressive mandate, including investigating all child deaths and critical injuries, monitoring how the child-welfare system functions and advocating for children. The current children's advocate's term should not be renewed when it expires this spring. A transitional advocate should be appointed while the new office gets set up.
GOV'T RESPONSE: It's being studied, but other recommendations take priority, said Family Services Minister Kerri Irvin-Ross.
Ease workers' caseloads
Social workers should have 20 cases apiece.
Gov't response: Doable and underway. Already, workers on the "family enhancement" side have only 20 cases each so they can work intensively with families to keep kids from being apprehended. Social workers who work on the child-protection side have about 25 cases each.
CFS staff should be required to keep complete and accurate records of all involvements with children and their families, including records of all services they deliver, including the reasons a case file was closed.
GOV'T RESPONSE: A bit of a no-brainer, and underway.
New case-management software
All agencies should get a new information-management system able to keep track of all children receiving protection services as well as all children in care. It should contain a feature that flags those known to pose a significant risk to children and it should be able to meld with other government systems, including health, education and employment insurance. It should be part of the next budget.
GOV'T RESPONSE: Underway. The government is looking at the scope of the IT overhaul and hasn't put a price tag on the project yet.
Social work degrees
Anyone practising social work in Manitoba, whatever their title, should be registered by the Manitoba College of Social Workers. Those working in child welfare ought to have a proper bachelor of social work degree.
GOV'T RESPONSE: The province doesn't know how many front-line staff have BSWs, but that recommendation is under review. Meanwhile, Irvin-Ross wants the plans to proclaim legislation setting up the MCSW on her desk by the end of May.
A key theme of the Hughes report, which called for better voluntary and early intervention services by placing child-welfare workers in schools, community centres, housing developments and anywhere else they might be easily accessible to families. The services needed to help families before they break down should be developed, co-ordinated and made accessible through partnerships with non-profits already working in the community.
GOV'T RESPONSE: A new focus on prevention is already underway, but Hughes' specific recommendations are under review and it's not clear how much they will cost.
'Aging out' at 25
When kids turn 18 or 21, provincial rules say child-welfare services must be withdrawn. The Hughes report recommends extending the "aging out" limit to 25 so kids who need helps as they move toward independence get it.
GOV'T RESPONSE: Under review.
That the premier of Manitoba raise the issue of the disproportionate number of aboriginal children taken into care by child-welfare authorities across Canada as a national issue at the next premiers' meeting.
GOV'T RESPONSE: Premier Greg Selinger has already raised the issue with first ministers who are supportive of putting the matter on the agenda at their next meeting -- in Charlottetown, P.E.I., Aug. 26-30.
-- Larry Kusch and Mary Agnes Welch