The 2006 report by Winnipeg Child and Family Services and two other reviews were released in their entirety for the first time Wednesday. Only portions of the documents had been released previously at a public inquiry into the girl's death that started last fall.
"Most of the intervention in this case ... seems to be phone calls or visits by social workers to 'warn and caution' the family. It is clear this intervention was unsuccessful in resulting in any noticeable change within the family," the report states.
"Perhaps if this case had been kept open for an extended period of time, a social worker could have developed ... a trusting relationship with this family and positive change could have been supported. If no change had occurred through intense proactive involvement, perhaps Phoenix would have been removed from the parents' care on a permanent basis with a clear rationale why it was necessary."
Manitoba child welfare has already been roundly criticized for failing to protect Phoenix. She was seized from her parents, Samantha Kematch and Steve Sinclair, after being born in April 2000 because the couple had a history of violence and was not prepared to care for her.
The inquiry has already heard that social workers frequently failed to keep track of Phoenix and would give her back to one or both of her parents without enforcing conditions such as parenting courses or addictions treatment.
In the summer of 2000, Phoenix was returned to her parents under a plan that included in-home support and parenting classes. The plan was never enforced and social workers didn't see the family for months.
In 2003, after her parents had split up, Phoenix was seized from her father after a day-long drinking party at his home where suspected gang members were present. Sinclair was ordered to undergo alcohol counselling before he could regain custody and had told social workers he wasn't ready to parent again.
But within a few months, Phoenix was given back to Sinclair, even though he had not undergone treatment. Her file was closed with no followup.
"This action is even more alarming as the social worker states that Steven did nothing to make changes in his life during Phoenix's time in care," the review says.
"Regardless of parental wishes, a period of after-care monitoring and support should be mandatory."
In 2004, Phoenix was being cared for by a family friend named Rohan Stephenson under an informal arrangement approved by Winnipeg Child and Family Services. The agency had told him not to give Phoenix back to either of her parents, but he returned the girl to Kematch anyway and did not tell the agency.
The informal agreement is criticized by another review released in its entirety Wednesday — this one from the chief medical examiner's office.
"The agency, by condoning a private arrangement ... afforded Phoenix no protection at all," it says.
"(Stephenson and his wife) had no legal authority to withhold Phoenix from either of her parents and no legal compulsion ... to report her removal from the home."
Unbeknownst to social workers, Phoenix's mother was by that time living with Karl McKay, a man with a long history of domestic violence that was outlined in the family services central database.
Two months before the girl's death in June 2005, two social workers acted on an anonymous tip that she was being abused and visited the family's Winnipeg apartment. They talked only to Kematch, who said she had company and kept them in the hallway. They left without seeing Phoenix and closed the file.
Shortly after that visit, Kematch and McKay moved to a house on the Fisher River reserve. They neglected and abused Phoenix, sometimes shooting her with a BB gun, and forced her to eat her own vomit. She was often confined to the unfinished concrete basement.
One of McKay's sons witnessed the 15-minute assault that killed Phoenix. It was McKay who delivered the final blows, the son told the inquiry earlier this week. McKay and Kematch then wrapped up the girl's body in plastic and buried her at the dump.
Her death in 2005 went undiscovered for nine months. McKay and Kematch continued to collect welfare payments with Phoenix listed as a dependent.
McKay and Kematch were arrested in March 2006 and were convicted of first-degree murder.
The inquiry is expected to conclude later this year with recommendations to follow on how to improve child welfare in the province.
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