The Keystone Kops could have done a better job of running Winnipeg Child and Family Services than the lot they had working during Phoenix Sinclair's short life.
A stunning pattern of malfeasance is coming clear at the inquiry into her death. Social workers rotated on and off the Sinclair file. Caseloads were too large to handle properly. Training was inadequate and note-taking a lost art. Cases were prioritized and the ones that weren't considered high-risk (although surely all CFS cases carry an element of risk) were shuffled to the bottom of the pile. The case of Phoenix and her parents, Steve Sinclair and Samantha Kematch, was not considered high-risk.
In fact, there were periods when it was not considered at all. A Section 10 report after Phoenix's death noted there was "minimal (CFS) contact" with the couple until the birth of Kematch's third child in 2001.
Social worker Delores Chief-Abigosis held the file in 2001 when Samantha Kematch went to hospital to give birth for the third time. She didn't know Kematch was pregnant. Granted, Kematch had a history of hiding her pregnancies, but it doesn't sound like her worker was looking at her very carefully.
Echo was born when Kematch was 19. Her first child, born when she was 16, was seized at birth and made a permanent ward of CFS, lucky duck. A file note reveals Kematch had a second chance with him but "was not able to feed him or meet his basic needs."
So Chief-Abigosis gets a call from a social worker at the hospital, alerting her to the new baby. She does not come to HSC to visit the family. They are sent home with their newborn. A hospital note indicates the social worker would follow up in the community with Mom, Dad, Phoenix and baby.
Did she? Chief-Abigosis has yet to testify, so all we have to go on is the family's thick file. CFS thought things were going so well with Kematch and Sinclair when baby Echo was born they considered closing the file.
On May 9, a visit by CFS was made to the home. No one was there. By July, concerns were raised about the care of the children. Kematch was allegedly drinking up the Child Tax Benefit. The couple had separated and Sinclair was the primary caregiver for his daughters. CFS knew he had been charged with assaulting Kematch. That didn't move them to the top of the priority list.
Chief-Abigosis left the agency in mid-July 2001. Social worker Kathy Peterson Epps, who had been Steve Sinclair's worker when he was a kid, caught the file in August. There was no contact during that time. The family was one of 30 on Peterson Epps' caseload. There was no transition meeting with Chief-Abigosis.
It was Peterson Epps, acting informally at the request of Steve Sinclair and his sisters, who learned the wheels had fallen off. She wrote a memo to Chief-Abigosis while she was still handling the case and placed it on her desk.
Sinclair told Peterson Epps he didn't know he still had a social worker.
There was a newborn and a one-year-old, a mother who was abusing alcohol, and two girls being cared for by a family friend the social worker had never met. This wasn't child welfare. It was neglect.
They played the pass-the-parcel game with Phoenix from birth. She was one of countless babies born into poverty and despair, so common she didn't rate on the risk scale. CFS was concerned enough about her mother they scheduled her for a pysch assessment, but when the appointment came, they had not armed the psychiatrist with concerns expressed by prior workers and her foster mother.
It was practically drive-thru psychiatry, an assessment done by a doctor unburdened by Kematch's history and unaware she had a grocery list of mental-health concerns in her past. His job was to diagnose depression, he testified, and he didn't find her depressed. The pity is his verdict transformed into a larger and inaccurate truth: There was nothing mentally wrong with the woman who would eventually kill her child.
Despite the surfeit of experts in her young life, Phoenix Sinclair was no more than a series of scribbled, fragmented notes. If anyone was connecting the dots between past and present, maternal and paternal history to immediate danger, it has not been obvious at the inquiry into her death.