Five-year-old Phoenix Sinclair was killed by the couple in 2005 after prolonged and horrific abuse.
In his final report into her death, Commissioner Ted Hughes recommended Manitoba should take the lead to address the disproportionate number of aboriginal children in care across Canada.
"At least 13 times throughout her life, Winnipeg Child and Family Services received notice of concerns for Phoenix's safety and well-being from various sources, the last one coming three months before her death," Hughes wrote in his three-volume report released Friday. "Throughout, files were opened and closed, often without a social worker ever laying eyes on Phoenix.
"Unfortunately, the system failed to act on what it knew, with tragic results."
Phoenix was apprehended at birth and during her life 27 agency workers were involved in her file. She was repeatedly returned to her mother, Samantha Kematch, despite concerns about what the judge called the woman's indifference toward her daughter.
Kematch and Karl McKay neglected, confined, tortured and beat Phoenix. She ultimately died of extensive injuries on the cold basement floor of the couple's home on the Fisher River reserve. She was buried in a shallow grave by the community dump and Kematch continued to collect child subsidy cheques.
Both adults were convicted of first-degree murder in 2008.
Hughes said the little girl's fate was sealed once Kematch began her relationship with McKay and took custody of Phoenix in 2004. He was "a dangerous man, from whom the agency could have, and should have, saved Phoenix," the judge wrote.
"Phoenix was defenceless against her mother's cruelty and neglect, and the sadistic violence of McKay, whose identity was never researched by the agency, but about whom it had ample disturbing information," Hughes continued. "By not accessing and acting on the information it had, and by not following the roadmaps offered by clear-thinking workers, the child-welfare system failed to protect Phoenix and support her family."
The inquiry cost $14 million, sat for 91 days and heard from 126 witnesses. Hughes made 62 recommendations while noting that improvements have been made to the system, but more needs to be done.
He said child-welfare agencies must assess the well-being of a child when a family comes to their attention — something he emphasized requires face-to-face contact. Social workers, their agencies and community organizations must all do a better job of communicating with each other on active files, he said.
Each social worker should also be responsible for no more than 20 cases, he said. Testimony at the inquiry heard some workers were responsible for twice that many.
Manitoba must also push aboriginal children in care onto the national agenda, Hughes suggested. More aboriginal children are taken from their homes not because they are aboriginal, but because they are living in poverty and their parents often suffer from addictions.
"It is a problem that extends beyond the boundaries of Manitoba."
Manitoba Family Services Minister Kerri Irvin-Ross said Premier Greg Selinger has already raised the issue with several premiers who support discussing it at their next meeting.
The province is also drafting legislation to make the reporting of critical incidents mandatory.
The province accepts Hughes's recommendations and will determine how to put them into practice, Irvin-Ross said.
"We are doing this because we want to move away from a culture of secrecy and individual blame and toward a culture of safety and learning focusing on protecting our children," the minister said.
"The child welfare system failed Phoenix Sinclair."
Kim Edwards, a woman who cared for Phoenix for much of her life, said she was pleased with the report and hopes that its recommendations will be followed.
"I feel a little less weight on us," she said.
But Edwards said she's skeptical that the government and child-welfare agencies will implement all the recommendations.
Grand Chief Derek Nepinak of the Assembly of Manitoba Chiefs said aboriginal people don't want greater centralization of a system that takes children away from their culture.
He said he would rather see more focus on the expertise of elders and support for a generation of parents still suffering from the legacy of residential schools.
"There is a genocide that's continuing to happen. The precedent for apprehension of children against the will of families started in the residential school era," he said. "It's still happening today.
"We have to work on creating a healing mechanism for families and that is not enough of a focus right now."