WINNIPEG -- An inquiry judge has found Manitoba child welfare fundamentally misunderstood its mandate to protect children and failed to save a five-year-old girl who was murdered.
Commissioner Ted Hughes says in his report into the death of Phoenix Sinclair that she was left "defenceless against her mother's cruelty'' and the "sadistic violence'' of the woman's boyfriend.
Hughes is recommending Manitoba 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.''
The little girl was killed by her mother and the woman's boyfriend in 2005.
Phoenix was apprehended at birth and, throughout her life, 27 different 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 her boyfriend, Karl McKay, neglected, confined, tortured and beat Phoenix. She ultimately died of her 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. McKay 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, which cost $14 million, sat for 91 days and heard testimony from 126 witnesses. Hughes has made 62 recommendations, noting that improvements have been made to the system, but there is still more work to be done.
He said child-welfare agencies must assess the safety and well-being of a child when a family comes to their attention _ something he emphasized requires face-to-face contact.
Each social worker should also be responsible for no more than 20 cases, he said. Workers should be properly trained on the inter-generational impact of residential schools and hold a degree in social work or an equivalent, Hughes said.
Manitoba must also work to force aboriginal children in care onto the national agenda, Hughes suggested. Across Canada, he said, more aboriginal children are taken from their homes _ not because they are aboriginal _ but because they are living in poverty and their parents are often suffering from addictions.
"It is a problem that extends beyond the boundaries of Manitoba,'' Hughes wrote. "It is a serious national problem and it needs to be tackled at a national level.''
Manitoba Family Services Minister Kerri Irvin-Ross said Premier Greg Selinger has already asked of his fellow premiers that the matter be discussed at an upcoming meeting.
She said the province is also drafting legislation to make the reporting of critical incidents mandatory, similar to the way they are in the health system.
"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,'' she said.
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