Despite the many errors, some critical, made in the handling of Phoenix Sinclair's file by child welfare workers through the short life of the little girl, no one at Winnipeg CFS was reprimanded or required to take remedial training. The mistakes, in aggregate, saw the five year old fall further and further into risk. She was murdered by her mother and stepfather in 2005.
That is remarkable. Over months of testimony at the public inquiry into Phoenix's life, it has become clear that some workers did not fulfil their duty of care and should have been asked to account for their errors and learn from them.
That didn't happen. Part of the explanation might lie in revelations this week that someone, up high, decided that three reviews conducted in the wake of Phoenix Sinclair's grisly death -- which was not discovered for nine months, despite the fact CFS was warned she was in danger -- would be kept secret.
Two of the reviews were conducted externally: one by the chief medical examiner's office and another under child welfare law by the provincial children's advocate office. A third was an internal file review of Winnipeg CFS's contact with the girl and her parents. They contain scathing assessments of the work done, notations of specific errors and instances where conduct was below professional standards. The report writers also found employees often were under stress and juggling heavy workloads.
This week, former Winnipeg CFS head Darlene MacDonald told the inquiry that while those kinds of reports were typically shared with agencies, supervisors and line workers, this case was different. MacDonald got word from up high to keep it all to herself.
In 2006, when the province released its sweeping review of the CFS system, it listed the changes ordered. Children receiving services were to be seen, face to face, by workers -- Phoenix was rarely seen despite the many hands that touched her file. That should have been standard practice of anyone who had the duty to ensure the safety of children.
Over the course of the agency's contact with the Sinclair file, workloads were rising and workers cut corners. Risk became relative, with deadly effect in Phoenix's case. But there were pointed findings about numerous errors made and loose compliance with best practices and standards in the three reports.
Front-line workers and supervisors, however, only learned of these criticisms and assessments while preparing for the inquiry.
The inquiry needs to find out who told Ms. MacDonald to keep the salient lessons of the reviews to herself, and why. As haphazard as the care became at a child welfare agency amid the disruption of structural change, the decision to hide the investigations' findings impeded what should have been a natural course of introspection, education and accountability.
This is symptomatic of a system that fights to keep its mistakes out of the public eye. The provincial government refuses to release publicly the mandated reports written whenever a child who had been receiving services from CFS dies -- called Sec. 4 reviews. It expects Manitobans to take its word that mistakes are identified and learned from, that the deaths of children do not pass into distant memory, in vain.
The inquiry's revelation shows how self-serving is that policy. It allows critical errors or wrong-doing to be swept under the carpet and for political masters who blanche at the prospect of real accountability to hide behind their public bromides. It bestows an impunity on external evaluators to declare -- as was done following the 2006 review of the system -- that no death of a child in care was ever the result of action or inaction by child welfare authorities.
The full story of Phoenix Sinclair's case is yet to be told, as are its lessons. But Family Services Minister Jennifer Howard must admit to the insidious effect of a policy that denies the public scrutiny of evaluations done when child welfare agencies fail to protect children. She must make redacted Sec. 4 reports public.