The Phoenix Sinclair commission has just entered its third week of public hearings into the tragic life and grisly death of the young girl, whom the child welfare system knew was at risk from birth, and one conclusion is apparent. It makes no sense to conduct repeat investigations in the wake of the deaths of these children -- she is not the only child to die in the shadow of the system -- if the findings are not shared with those whose actions were faulty.
There were three reviews conducted in 2006, when Phoenix's death was discovered nine months after her mother and her mother's boyfriend hid her body at a dump near their Fisher River home. A former program manager of Winnipeg CFS, the agency charged with keeping her safe, completed an internal review. The chief medical examiner's office did its own file review of the agency's role in Phoenix's life and an investigation under the CFS Act, called a Sec. 4 review, was also conducted.
While commission counsel Sherri Walsh noted that some people were interviewed for some of that work, those social workers who have testified of their own involvement so far say they were never spoken to and did not see the results until the commission began its work.
That's astounding. Some reviews, such as the internal CFS look-back, are meant to be rapid "paper reviews." But the provincial investigation is extensive and intended to look deeper to detect weaknesses in the system Manitoba uses to protect vulnerable children from neglect and abuse. How can the full story be told in the absence of speaking to those who made the notes, filed the paper, made the decisions on how families and children get the services necessary to keep homes intact, or to pull kids into safer places?
Social workers testified they never saw the conclusions, the many findings and recommendations that commented on their personal work in the file. Much of Laura Forrest's work was lauded, but she was found professionally remiss in the fact that for weeks she failed to see Phoenix personally to confirm her safety. It would have been helpful to know the reviews' comments on her shortcomings, she told the inquiry last week.
Some workers said some of the findings were wrong -- the suggestion that Phoenix's father Steve Sinclair was left without grief counseling when Phoenix's newborn sister Echo died in 2001, for example.
Contrast these investigations to those of the provincial auditor's office (Crocus) and ombudsman's office (recent whistleblower complaint about a nursing home's misuse of funds). These offices interview all actors deemed important and then present their findings to them for comment. The provincial auditor releases its report publicly; the ombudsman doesn't release whistleblower reports.
In both cases, the provincial government then moved quickly to halt mismanagement of money.
It took the provincial government three years to make changes, in 2009, in the way child-protection cases are handled, including mandatory face-to-face visits with children under the watch or in the care of CFS agencies. All the while, these workers were oblivious to their wrongdoings.
Fundamental changes need to be made in the conduct, and sharing, of investigations following a child's death. These reports are secret, never publicly released unless an inquiry is held into a profound failing of the system, as happened with Phoenix. That secrecy complicates problems. There is no good reason to withhold the provincial review, the Sec. 4 investigation, from public release.
That's something Family Services Minister Jennifer Howard can correct right now.