An inquest report on the death of a 20-month-old girl returned to her drug-addicted mother goes through a litany of numerous critical details where a child-welfare agency failed in its duty to keep her safe. The stunning lack of attention to the risk posed to the child by her mother, ignorance of the mother's drug use, the return of the child to the woman without evidence it was safe to do so.
This reads like a story of many children who died while in the "care" of Child and Family Services agencies before fundamental reforms were triggered after the 2005 murder of five-year-old Phoenix Sinclair.
Yet, Jaylene Star Redhead was smothered by her drug-addled mother in mid-2009, while they were living at the Native Women's Transition Centre in Winnipeg. This, after stacks of investigations and inquiries and reports have piled up and regulations and rules written to prevent all that went wrong in this case.
Nicole Redhead, subsequently convicted of manslaughter and sent to prison for 12 years, suffocated her daughter to stop her from crying -- the toddler was found to carry numerous bruises from repeat abuse and beatings, including to her vagina.
Awasis, the agency in control of this case, employed workers at salaries $7,000 below counterparts elsewhere and loaded them with work. Some front-line staff juggled as many as 50 cases -- despite repeat recommendations from past inquiries compelling the province to address such conditions.
Documentation and filing, as a result, were not priorities, and so the risk Nicole posed to her child was obscured. The worker who agreed Nicole could live at the Native Women's Transition Centre in late 2007 had reviewed only a pamphlet on the centre and assumed it was a secure residence.
It wasn't. Doors were open, and residents regularly used drugs.
Nicole was abusing substances throughout her stay there, was leaving to party on the weekends and receiving no counselling adequate to her needs.
Awasis, relying on the uninformed reports from the transition centre, accepted that Nicole, who had lost her two younger sons due to drug abuse, was making progress and ready to live with her toddler, despite the fact the woman was again pregnant (for a second time while at the centre; she aborted the first).
Testimony at the inquest showed numerous flaws in supervision, assessment of risk, demands for documented proof of counselling -- there was no set agreement between the agency and the centre on a plan for Nicole.
Evidence showed Jaylene was almost fated to fall back into her mother's hands: Awasis's primary mission was to return children to parents as long as parents wanted to work toward that goal. The transition centre's focus, meanwhile, was to get abused or addicted women back on their feet.
It's clear no one had Jaylene as their primary concern. This despite the fact the safety of the child is the primary concern in the Child and Family Services Act.
Provincial court Judge Lawrence Allen made repeat recommendations in his inquest report, released Friday, flowing from the specifics of this specific death. They focus on adequate training, documentation, agreements for service and case-load management.
Much of this has been regulated previously.
Equally worrisome was his finding that the investigation report prepared by the Office of the Children's Advocate was all but unreliable -- due to the lack of time and money, people central to the tragedy were not interviewed. Further, there is an abiding distrust and finger-pointing between all the agencies involved.
Family Services Minister Kerri Irvin-Ross has been led to believe, in the wake of the recent inquiry into Phoenix Sinclair's death, that child-welfare agencies are getting in better shape to keep children safe. This inquest reveals is blissful ignorance.
Ms. Irvin-Ross needs to do an audit of case files to ferret out agencies and workers that continue to put the interests of dangerous parents ahead of the need to protect vulnerable children. The death of Jaylene Redhead shows huge holes still exist, and children are falling into them.