System failed to protect Phoenix Sinclair from killer mom and boyfriend: Inquiry
An inquiry report on the tragic life and death of Phoenix Sinclair finds a systemic child welfare failure prevented action that could have saved her life.
And it’s calling for a sweeping overhaul of the province’s child welfare system to ensure that doesn’t happen again.
The lengthy $14-million inquiry into the death of the five-year-old girl involved with Child and Family Services explored how the system failed to protect her. Despite being taken into care twice, as a newborn and at the age of three, Phoenix Sinclair wound up in the care of her mother Samantha Kematch and mother’s boyfriend Karl Wesley McKay. The couple beat, then killed her in June 2005 in Fisher River but the death was not discovered until March 2006.
Family Services Minister Kerri Irvin-Ross apologized for the failures of the system Friday.
“The system isn’t perfect. The system broke down and a child was murdered,” she said.
The province vowed to “immediately act” on all of the report’s 62 recommendations. Yet when pressed, Irvin-Ross would not commit to some adjustments to legislative changes, accountability and a professional act for social workers. Those items are still being analyzed, she said.
Phoenix’s loved ones welcomed the recommendations but feared they won’t be enforced since previous reports called for similar reforms.
“I, the woman who raised her, wanted to get justice for her and I think that we’ve accomplished that in regards to the commissioner’s recommendations ... as far as implementing the changes, I can’t really comment as to whether it’s going to happen because I’ve read the reports and they all read the same,” said Kim Edwards, Phoenix’s foster mother.
Meanwhile, Edwards fears the little girl’s death could be in vain unless the changes are implemented and enforced.
Commissioner Ted Hughes’ report notes that while “social and economic conditions that render a child vulnerable to abuse and neglect are well beyond the scope of the child welfare system,” that system still failed repeatedly to address at least 13 notices of concern for Phoenix’s safety.
“Throughout, files were opened and closed, without a social worker ever laying eyes on Phoenix,” wrote Hughes.
Plenty of opportunities were missed because workers did not ensure face-to-face contact with Phoenix after reports of abuse. Face-to-face visits are now a mandatory monthly practice, Irvin-Ross said.
Hughes is calling for an extension of children in care at age 18 to receive individual workers and support services until age 25, a new CFS information system and that caseloads be reduced to 20 children per social worker.
He also suggests the province reduce caseloads to 20 children per social worker, increase social assistance housing allowances to 75% of the median market rate and raise a $1,300 fund for family enhancement services to a “reasonable level.”
The province isn’t sure how much implementing all of the recommended changes would cost.
A summary of the Phoenix Sinclair inquiry report's 62 recommendations:
1) Use early intervention to support families at risk and guarantee face-to-face contact to assess child safety.
2) Co-ordinate and collaborate for better family support services.
3) Follow triage and short-term services with a transfer to a family services unit as soon as possible.
4) Assign the same worker to a family once they've become involved in the system whenever possible.
5) Have workers passing files on discuss them and record that conversation to ensure all concerns are communicated.
6) Strive for greater transparency with caregivers.
7) Place child and family service workers in schools, community centres and housing developments to make them more accessible.
8) Train all workers to use Structured Decision-Making assessment tools.
9) Alter legislation to allow service providers to better share information with parents, caregivers and other service providers.
10) Have committee discussions of policies and programs at each CFS authority as a regular agenda item.
11) Have a committee issue annual reports on the above.
12) Deliver all ongoing services to families on the basis of 20 cases per worker.
13) Explore ways to reduce administrative burdens on social workers.
14) Designate staff at each authority who are available during daytime and after hours to locate individuals and serve court documents.
15) Require workers to keep complete and accurate records of every child and family, including services delivered and communications.
16) Require consultants delivering a service to a family involved with CFS file a written report to be added to the child's file.
17) Track every telephone call the agency receives.
18) Create a policy to govern retention of records.
19) Develop and implement a supervision policy including annual performance reviews, records of meetings between supervisors and workers and documented reasons for closing or transferring a file.
20) Complete annual reviews of well-being for children receiving services.
21) Complete the "solution-scoping phase" to replace the CFS information management system with a new one in the current fiscal year.
22) Select a new information system that can integrate with other government systems, track children leaving care and add alerts about individuals known to pose a threat to a child.
23) Require all agencies to use the above new system.
24) Ensure all agencies can access the new system.
25) Fund authorities to support a caseload of 20 cases per worker and an increase to the $1,300 family enhancement services fund to a "reasonable level."
26) Require a bachelor of social work or equivalent degree for all social workers.
27) Encourage aboriginal people to enter the social work profession.
28) Share information on training programs and tools between authorities.
29) Train workers on the impact of residential schools, poverty, poor housing, substance abuse and other social and economic factors in assessing child neglect.
30) Share relevant information from any CFS investigation with staff.
31) Share findings of this report be shared with all CFS staff.
32) Ensure the transitional board established under The Social Work Profession Act complete its work and reports to the minister by June 30, 2014.
33) Ensure the act requires the registration of all Manitoba social workers and is proclaimed into law at the earliest date possible.
34) Extend child and family services to age 25 for any child still in care at age 18.
35) Ensure the above extension for young adults involves an individual social worker to co-ordinate services.
36) Establish a Manitoba Representative for Children and Youth position to replace the current child advocate.
37) Have the legislative assembly appoint that representative.
38) Give the representative a five-year term, with an option to serve a second one but no more than 10 years.
39) Appoint a deputy representative.
40) Establish a Standing Committee on Children and Youth at the legislature.
41) Require the representative to provide an annual service plan with goals and performance measures and annual report on their own work.
42) Release to the public all annual reports, special reports and service plans.
43) Use aboriginal understanding as hiring criteria for staff of the office of the representative.
44) Appoint an acting children's advocate at the end of the current term to ensure a smooth transition to the representative position.
45) Require the representative to fulfill duties of providing services and reporting on critical injuries and deaths of children.a
46) Consider B.C.'s Representative for Children and Youth Act in drafting new legislation.
47) Remove the responsibility of the Ombudsman with respect to special investigation reports.
48) Use a public awareness campaign to inform about the role of the representative.
49) Lead a provincial effort to improve affordable housing access.
50) Review the 2009 "The View From Here" poverty reduction plan and implement outstanding recommendations.
51) Increase social assistance housing allowances to 75% of the median market rate to alleviate the link between poverty and family vulnerability.
52) Expand supports for families transitioning from first nations communities to urban centres.
53) Request Manitoba Premier Greg Selinger be able to speak to the disproportionate number of aboriginal children taken into provincial care at the next Council of the Federation meeting and, if permitted, use that time to seek national solutions to the problem.
54) Amend the Healthy Child Manitoba Act to reflect the United Nations Rights of the Child.
55) Enhance the capacity of community-based organizations through sustained long-term funding to ensure a more holistic delivery of services.
56) Co-ordinate, through a legislated committee, the services for children and families and allocate funding to community-based organizations.
57) Have CFS accommodate reasonable requests by parents and caregivers for an individual helping the family beyond the system to participate with the system.
58) Have child welfare agencies meet regularly with community-based organizations that help their clients.
59) Legislative delivery of early childhood development programs with trained educators. Make these voluntary but universally available.
60) Establish integrated service delivery centres with early childhood education, public health, social housing, employment assistance and other supports.
61) Allocate funding for the above service centres.
62) Integrate aboriginal culture and history, including colonization and the impact of residential schools, into the provincial curriculum.
‘The system broke down and a child was murdered’ | Manitoba | News | Winnipeg Sun
It sickens me that we can find $14 million to hold an Inquiry yet we can't find the additional resources needed to improve the system until someone dies. And even then. How many of these recommended changes do you think will be in place when the next Inquiry is held?
My heart breaks every time I see a photo of the poor child.
An inquiry report on the tragic life and death of Phoenix Sinclair finds a systemic child welfare failure prevented action that could have saved her life.
And it’s calling for a sweeping overhaul of the province’s child welfare system to ensure that doesn’t happen again.
The lengthy $14-million inquiry into the death of the five-year-old girl involved with Child and Family Services explored how the system failed to protect her. Despite being taken into care twice, as a newborn and at the age of three, Phoenix Sinclair wound up in the care of her mother Samantha Kematch and mother’s boyfriend Karl Wesley McKay. The couple beat, then killed her in June 2005 in Fisher River but the death was not discovered until March 2006.
Family Services Minister Kerri Irvin-Ross apologized for the failures of the system Friday.
“The system isn’t perfect. The system broke down and a child was murdered,” she said.
The province vowed to “immediately act” on all of the report’s 62 recommendations. Yet when pressed, Irvin-Ross would not commit to some adjustments to legislative changes, accountability and a professional act for social workers. Those items are still being analyzed, she said.
Phoenix’s loved ones welcomed the recommendations but feared they won’t be enforced since previous reports called for similar reforms.
“I, the woman who raised her, wanted to get justice for her and I think that we’ve accomplished that in regards to the commissioner’s recommendations ... as far as implementing the changes, I can’t really comment as to whether it’s going to happen because I’ve read the reports and they all read the same,” said Kim Edwards, Phoenix’s foster mother.
Meanwhile, Edwards fears the little girl’s death could be in vain unless the changes are implemented and enforced.
Commissioner Ted Hughes’ report notes that while “social and economic conditions that render a child vulnerable to abuse and neglect are well beyond the scope of the child welfare system,” that system still failed repeatedly to address at least 13 notices of concern for Phoenix’s safety.
“Throughout, files were opened and closed, without a social worker ever laying eyes on Phoenix,” wrote Hughes.
Plenty of opportunities were missed because workers did not ensure face-to-face contact with Phoenix after reports of abuse. Face-to-face visits are now a mandatory monthly practice, Irvin-Ross said.
Hughes is calling for an extension of children in care at age 18 to receive individual workers and support services until age 25, a new CFS information system and that caseloads be reduced to 20 children per social worker.
He also suggests the province reduce caseloads to 20 children per social worker, increase social assistance housing allowances to 75% of the median market rate and raise a $1,300 fund for family enhancement services to a “reasonable level.”
The province isn’t sure how much implementing all of the recommended changes would cost.
A summary of the Phoenix Sinclair inquiry report's 62 recommendations:
1) Use early intervention to support families at risk and guarantee face-to-face contact to assess child safety.
2) Co-ordinate and collaborate for better family support services.
3) Follow triage and short-term services with a transfer to a family services unit as soon as possible.
4) Assign the same worker to a family once they've become involved in the system whenever possible.
5) Have workers passing files on discuss them and record that conversation to ensure all concerns are communicated.
6) Strive for greater transparency with caregivers.
7) Place child and family service workers in schools, community centres and housing developments to make them more accessible.
8) Train all workers to use Structured Decision-Making assessment tools.
9) Alter legislation to allow service providers to better share information with parents, caregivers and other service providers.
10) Have committee discussions of policies and programs at each CFS authority as a regular agenda item.
11) Have a committee issue annual reports on the above.
12) Deliver all ongoing services to families on the basis of 20 cases per worker.
13) Explore ways to reduce administrative burdens on social workers.
14) Designate staff at each authority who are available during daytime and after hours to locate individuals and serve court documents.
15) Require workers to keep complete and accurate records of every child and family, including services delivered and communications.
16) Require consultants delivering a service to a family involved with CFS file a written report to be added to the child's file.
17) Track every telephone call the agency receives.
18) Create a policy to govern retention of records.
19) Develop and implement a supervision policy including annual performance reviews, records of meetings between supervisors and workers and documented reasons for closing or transferring a file.
20) Complete annual reviews of well-being for children receiving services.
21) Complete the "solution-scoping phase" to replace the CFS information management system with a new one in the current fiscal year.
22) Select a new information system that can integrate with other government systems, track children leaving care and add alerts about individuals known to pose a threat to a child.
23) Require all agencies to use the above new system.
24) Ensure all agencies can access the new system.
25) Fund authorities to support a caseload of 20 cases per worker and an increase to the $1,300 family enhancement services fund to a "reasonable level."
26) Require a bachelor of social work or equivalent degree for all social workers.
27) Encourage aboriginal people to enter the social work profession.
28) Share information on training programs and tools between authorities.
29) Train workers on the impact of residential schools, poverty, poor housing, substance abuse and other social and economic factors in assessing child neglect.
30) Share relevant information from any CFS investigation with staff.
31) Share findings of this report be shared with all CFS staff.
32) Ensure the transitional board established under The Social Work Profession Act complete its work and reports to the minister by June 30, 2014.
33) Ensure the act requires the registration of all Manitoba social workers and is proclaimed into law at the earliest date possible.
34) Extend child and family services to age 25 for any child still in care at age 18.
35) Ensure the above extension for young adults involves an individual social worker to co-ordinate services.
36) Establish a Manitoba Representative for Children and Youth position to replace the current child advocate.
37) Have the legislative assembly appoint that representative.
38) Give the representative a five-year term, with an option to serve a second one but no more than 10 years.
39) Appoint a deputy representative.
40) Establish a Standing Committee on Children and Youth at the legislature.
41) Require the representative to provide an annual service plan with goals and performance measures and annual report on their own work.
42) Release to the public all annual reports, special reports and service plans.
43) Use aboriginal understanding as hiring criteria for staff of the office of the representative.
44) Appoint an acting children's advocate at the end of the current term to ensure a smooth transition to the representative position.
45) Require the representative to fulfill duties of providing services and reporting on critical injuries and deaths of children.a
46) Consider B.C.'s Representative for Children and Youth Act in drafting new legislation.
47) Remove the responsibility of the Ombudsman with respect to special investigation reports.
48) Use a public awareness campaign to inform about the role of the representative.
49) Lead a provincial effort to improve affordable housing access.
50) Review the 2009 "The View From Here" poverty reduction plan and implement outstanding recommendations.
51) Increase social assistance housing allowances to 75% of the median market rate to alleviate the link between poverty and family vulnerability.
52) Expand supports for families transitioning from first nations communities to urban centres.
53) Request Manitoba Premier Greg Selinger be able to speak to the disproportionate number of aboriginal children taken into provincial care at the next Council of the Federation meeting and, if permitted, use that time to seek national solutions to the problem.
54) Amend the Healthy Child Manitoba Act to reflect the United Nations Rights of the Child.
55) Enhance the capacity of community-based organizations through sustained long-term funding to ensure a more holistic delivery of services.
56) Co-ordinate, through a legislated committee, the services for children and families and allocate funding to community-based organizations.
57) Have CFS accommodate reasonable requests by parents and caregivers for an individual helping the family beyond the system to participate with the system.
58) Have child welfare agencies meet regularly with community-based organizations that help their clients.
59) Legislative delivery of early childhood development programs with trained educators. Make these voluntary but universally available.
60) Establish integrated service delivery centres with early childhood education, public health, social housing, employment assistance and other supports.
61) Allocate funding for the above service centres.
62) Integrate aboriginal culture and history, including colonization and the impact of residential schools, into the provincial curriculum.
‘The system broke down and a child was murdered’ | Manitoba | News | Winnipeg Sun
It sickens me that we can find $14 million to hold an Inquiry yet we can't find the additional resources needed to improve the system until someone dies. And even then. How many of these recommended changes do you think will be in place when the next Inquiry is held?
My heart breaks every time I see a photo of the poor child.