A lack of supervision at a Winnipeg transitional shelter helped lead to the death of a baby girl who was killed by her mother, a provincial judge has found.
Nicole Redhead suffocated her daughter, Jaylene, at the Native Women's Transition Centre, where alcohol and recreational drugs were used liberally.
The Awasis agency of Child and Family Services, which had returned the baby to Redhead even though they knew the mother had a history of severe crack addiction, had a mistaken belief about the level of supervision at NWTC, Judge Larry Allen found.
He cited a major communication gap between staff at CFS and staff at NWTC, which led to a faulty perception of the actual risk Redhead posed to her infant.
Allen's wide-reaching inquest report examining the death of baby Jaylene on June 29, 2009, was publicly released Friday.
The report's findings have prompted pledges from the province to improve aspects of the child-welfare system, including fostering greater collaboration between its various players.
Redhead is currently serving a 12-year prison sentence for manslaughter.
'This misapprehension of just what NWTC was is one of the reasons for the tragedy of Jaylene Redhead's death'
She admitted to killing Jaylene by suffocating her. The little girl also suffered physical abuse.
Redhead was nine months pregnant with another child at the time.
A mother to two prior children who had been seized by CFS, Redhead also saw Jaylene apprehended at birth in October 2007 because of a severe crack-cocaine addiction.
Redhead's personal background was marred by extreme trauma, abuse and addictions issues -- factors known to CFS.
She came to live at NWTC by January 2008 and by December was living in a more independent tier of housing there.
It was the fourth time Redhead had stayed at NWTC. She had chosen to leave on the prior occasions.
She regained custody of Jaylene under the provisions of a CFS "temporary supervision order."
A month later, she was back to using crack cocaine regularly.
The inquest was heard over 41 days between August 2012 and December 2013.
In addition to social workers, NWTC staffers and experts, it heard from past NWTC clients.
They described widespread and unchecked use of alcohol and drugs at the CFS-endorsed shelter around the time Redhead was living there.
Allen said a CFS requirement that Redhead undergo random drug testing was dropped "at some point" because it was felt she was staying at a "safe house."
A clinical psychologist who once assessed Redhead's capacity to parent called this development "a major miss."
CFS didn't know that not only was Redhead becoming intoxicated at NWTC but she was also taking weekend leaves, often leaving Jaylene with a relative to go "partying," the inquest heard.
In the months before Jaylene's killing, Redhead's CFS file was handed off to interim workers. Agency caseloads were consistently high and the social work suffered, the inquest heard.
One worker admitted not knowing why Redhead was living at NWTC or that she was considered a "high-risk" client with serious issues, Allen's report states.
The worker also believed NWTC to be a "secure facility," Allen wrote.
Her risk assessment was downgraded from high to low. Mere months later, Jaylene was killed.
This perception by CFS workers of NWTC as a "safe house" wasn't accurate, Allen suggests.
There was also an "inadequate understanding" between the two entities about which was responsible for what services for Redhead, Allen said.
"This misapprehension of just what NWTC was is one of the reasons for the tragedy of Jaylene Redhead's death," Allen states. "While it may be that the Awasis agency should have known more about where Nicole and Jaylene were going when away from the centre, they cannot be faulted for believing that NWTC was a safer environment than it actually was.
"Many of the (lawyers) involved in this matter and the court itself have been familiar with 'safe houses,' and NWTC in particular, for many years and I believe all of us were very much taken aback with the revelations as to drug use, lax enforcement of rules and lack of security at the facility," Allen wrote.
"The relationship between Awasis and NWTC appears to reveal poor communication of information and accordingly, poor information. Unfortunately, the reliance on this information was high. High reliance on poor information creates situations fraught with risk," Allen stated.
The death prompted an audit of NWTC by Manitoba's Child Protection Branch.
The centre's management has since undertaken extensive procedural and other changes, including adding after-hours staff and performing room checks for drugs and alcohol.
"The centre itself has gone a long way to rectifying perceived problems," Allen wrote. "The Awasis agency understandably appears to have misunderstood how NWTC was being run. It should never be the case again that the rules and practices of that facility are left as nebulous as they were preceding Jaylene Redhead's death," Allen said.