When Phoenix Sinclair slipped through Manitoba's child-welfare safety net, it was stretched thin and sagging under the weight of change, the inquiry into her death was told Thursday.
The woman at the helm of Winnipeg Child and Family Services from 2001 to 2004 testified the changes and related workload issues likely affected services rendered to the little girl.
In 2001, chief executive officer Linda Trigg wrote about a "decimated workforce" and programs under "significant stress" in a memo to provincial government staffers who had just taken over CFS from its community board.
Phoenix was born in 2000 and was in and out of care and on and off CFS's radar screen until she was murdered in 2005 by her mother, Samantha Kematch, and stepfather, Karl "Wes" McKay. They were convicted in 2008 and the province ordered an inquiry in 2011 to find out how Phoenix fell through the cracks of the child-welfare system.
Trigg testified Thursday that when she was seconded to run the province's largest agency, it was under a lot of pressure. Some of it was from earlier CFS changes that resulted in the least-experienced social workers doing the work that required the most skill and experience, she said.
Before 1999, when CFS went from area-based to program-based, social workers handled a variety of cases, she said.
"You could take a permanent ward out for lunch and spend the rest of the day on protection cases," said Trigg, who holds a doctorate in clinical psychology.
When workers had just one type of case, many with experience and seniority fled the front lines for less demanding and less dangerous work, she said.
"People with seniority worked in programs that did not have the same level of constant stress," she said.
"On the front line, there was a constant turnover,. Over 50 per cent there had less than two years' experience... The most junior people are filling some of the roles requiring the most sophisticated judgment."
When front-line workers and their supervisors closed the file on Phoenix Sinclair without seeing her or finding out about on her violent stepfather, lack of experience wasn't an issue. Several social workers testified there was no standard at the time that required them to see a child and, in their judgment, there were no known child-protection concerns regarding Phoenix. Many have said if workload wasn't an issue, they would have done more to make sure she was safe.
Trigg, their former boss, said there was confusion over standards at the time, but seeing a child in a case such as Phoenix's would have been expected.
"You could not do a child-protection investigation without having face-to-face contact with the child," Trigg said.
She said supervisors were responsible for training their staff and making sure they met expectations.
With a steady stream of new hires passing through the front-line revolving door, that would be difficult, she said. She said one supervisor had 100 per cent of her staff leave in one year.
For workers, there was job stress and anxiety about devolution and what would happen to them and their pensions once CFS was chopped in half and aboriginal child-welfare agencies were established, Trigg said.
"Were children ever put at risk because of workload issues?" commission counsel Sherri Walsh asked her.
"I would probably have to say yes," Trigg said. "I'm thinking about the Phoenix Sinclair case."
Her testimony continues Monday.