Another illuminating moment today at the inquiry into how Phoenix Sinclair fell through the cracks of our provincial child-protection system.
It had to do with the information social workers rely on when assessing the urgency — some may describe that as ‘risk’ — when responding to a case; specifically, how soon Phoenix needed the system’s attention.
I’ve written before about social worker Laura Forrest being lauded in at least one internal review after Phoenix’s death (as well as by CFS employees on the witness stand) regarding her June 2003 case summary, which finally put together all available information about the case and the concerning backgrounds of her parents.
Forrest saw that, all things considered, her case was high risk and that CFS couldn’t go away from her life.
Her risk assessment would ultimately be deemed an “opinion” by subsequent workers and tossed aside to allow Steve Sinclair a fresh start with CFS and a new worker after Phoenix was taken from him in June 2003.
By the time Sinclair regained custody of her on Oct. 2, 2003, colleague and case worker Stan Williams’s closing summary of the case looked starkly different than Forrest’s.
I won’t reprint Forrest’s in its entirety, it’s pages long and extremely deep (it can be found here) Below, however, is the final, but still lengthy section in her ‘Statement of Risk.’
“Steven and Samantha have clearly indicated their mistrust and unwillingness to be involved with a child welfare agency however they have not demonstrated a capacity and commitment to ensure their child’s wellbeing enough for the agency not to be involved. Unfortunately. because of their past involvement as wards of a child welfare agency they arc not receptive to services from the agency and they deny or minimize any Issues presented in an effort to keep the agency away from them. They would do anything, or nothing, to keep the agency at bay. It is this worker’s opinion that it is this attitude and disregard for the agency that has probably resulted in this agency’s previous termination of services, and not a lack of child welfare issues, If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse lssue(s), and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and / or placement in agency care. Phoenix Is in agency care no(w) and it would probably not be in her best interests to be returned to either parent at this time or until they can show something to indicate that they can and will be more responsible and protective other.”
Now, for the sake of contrast, here’s Stan Williams’s final word on the case, under the “Unresolved Problems‘ section. It was authored around the time Phoenix was allowed by CFS to go back to dad unconditionally without having taken any programming for his alcohol problem.
“Mr. Sinclair requested his child stay in care until he felt strong enough to care for her again. He has had his time out and will parent Phoenix starting Oct. 2, 2003. He has done no programming and as such is prone to an unhealthy way of managing stresses in his life. He is aware of the need to arrange for appropriate alternative caregivers when he feels the need for a break or time out for respite.”
It goes without saying there’s a massive difference between the tone, content and, I submit — the intent of the two statements, prepared mere months apart by different social workers with apparently different mindsets.
But the net effect of this apparent discretionary revisionism was revealed today in relation to how another social worker, Lisa Conlin (and, her supervisor) started off their investigation into subsequent allegations Phoenix could be at risk in January 2004.
Conlin says she didn’t or can’t remember looking at past Kematch or Sinclair files the agency had on record when the file came to her on Jan. 20, 2004.
Did you look up either of the parents’ information on CFSIS (the internal computer system)?, commission counsel Sherri Walsh asked.
“Well, I believe I for sure would have looked at his (inaudible) that was open to me,” she said.
At Steve Sinclair’s?
“Steve Sinclair’s. That would be my typical practice,” she said.
And what would you have looked at? What information would you have looked at?
“The last closing summary,” Conlin replied.
So in this case, that’s the one at November 2003 (The Williams closing summary, referenced above.)? What about the one immediately before that — still in Mr. Sinclair’s file, from March 2002 — would you have looked at that one as well?
“I don’t specifically recall that one.”
You don’t recall looking at that one?
Was it your practice, typically, just to look at the most recent file closing?
“Typically, because, what happens is the latest worker would have summarized already the previous closing summary — so you get a recent summary in the most recent closing. Just like when the intake initially comes to me from the Crisis Response Unit, there’s a summary … in there.” (To be fair, there was also a short ‘cut and pasted’ recounting of the family’s history and CFS involvement in that summary).
So if we look at the summary you would have reviewed … (Nov. 13, 2003, the Williams summary) under the heading ‘unresolved problems’ (Walsh reads the section, listed above, aloud to her)
“I don’t recall exactly when I looked at this,” she says. “It’s just something (as a matter of practice) I would have done,” said Conlin.
As you can clearly see, there’s a huge discrepancy in content and tone between the Forrest and Williams case summaries.
One (Forrest’s) darkly and deeply warns of the risk Phoenix was in and — by my reading — essentially urges the agency to stay involved in the little girl’s life.
The other, Williams’ laconic five-sentence-long summary essentially — to me — suggests almost the polar opposite – that the agency take a hands-off approach for the young dad who just needed a time out from parenting. (as if that wasn’t a warning sign in itself).
Problem is, when problems crept up again a few months later, Conlin, a busy social worker handling short-term child-protection intervention calls in the city’s most challenged area — likely only had so much time to delve into the file. Who knows. Maybe she just didn’t see the need to look further given the presenting child-welfare issues in the case she was to look into.
But it’s clear to me, at least, that it’s certainly more likely a social worker’s guard would have been raised significantly more if Forrest’s case summary had remained the one at the top of the pile.
“This is an inquiry and an inquiry we must now proceed to do with all possible diligence.” Ted Hughes
To describe as ‘heroic’ any of the witnesses who have testified at the Phoenix Sinclair inquiry so far could appear as faulty as some of the decision-making employees of Child and Family Services made over the duration of the little girl’s involvement with the child-welfare system circa 2001-2004 — the period which we’ve been learning about so far.
But it’s my opinion if there’s any one of them deserving of a good measure of our respect today, it’s Heather Edinborough, for the simple reason that her candour has clearly put us closer to what we’re supposed to be after here: The truth of how a little child fell off the radar of Manitoba CFS and suffered horribly because of it.
Before I get to why I believe Edinborough should be lauded (despite her admissions that several things in the Sinclair-Phoenix case weren’t done at all properly under her watch as a Winnipeg CFS Supervisor in 2003) there’s something I need to get off my chest about the inquiry and the role of the media.
And this is not a critique. Just an observation.
From this reporter’s perspective, the proceedings haven’t in any way been easy to cover.
The media, by and large, makes its hay by boiling things down into simple ‘opposition’ narratives reinforced by time-worn themes.
Good versus evil. Right battles wrong. David tackles Goliath.
Acknowledging this helps explain the overuse of the word ‘story/ies’ to describe the product readers and viewers consume and — in another sense — the newsgathering process itself.
“How’s that story coming, Turner?,” the editor barked.
Complexity is generally eschewed for the sake of the “story.”
But in the case of this inquiry, ‘boiling down’ or trying to make the information fit a story arc just won’t work.
I can’t see how it can happen and grow the public’s understanding of the machinations of our child-welfare system.
I am willing to accept my inability to see this could just speak to my skills as a journalist.
But if we’re going to get at the truth here and be able to communicate it meaningfully to shine light on Manitoba’s CFS system, it will only be done with the realization there is no easy 140-character narrative to do it through.
To unravel how Phoenix fell through the cracks and prevent other kids from the same fate, we’re going to have to wade far out into complexity and nuance; fully be OK with the undeniable fact it wasn’t ONE thing (say, incompetence) that led us to the sad place we’re at today.
Instead, it’s a whole host of circumstances at play inside an unwieldy and bureaucratic machine operating with a somewhat (it seems to me) contradictory mandate: protecting kids and trying to fix/reunite unhealthy families.
Couple the contradiction with the fact that how the mandate is fulfilled appears to involve huge amounts of discretion by various CFS actors, some performing the front line work (who don’t have standardized training) — it’s easy to see how things could go wrong.
But one of the things I was reminded of by Heather Edinborough’s testimony on Friday is this: The vast majority of people doing CFS work aren’t bad people. They’re people who believe they can make a positive difference in people’s lives despite inordinate and complex challenges coming at them each day, every day.
In summer 2003, Edinborough, a Winnipeg CFS supervisor and social worker Stan Williams set about trying to do the right thing for Phoenix’s dad Steve Sinclair using the tools of the system they had to work with.
A natural virtue of that, as I see the underlying reasoning, is if they reached Sinclair — gave him a “fresh start” — got him on a positive path, then the system’s ultimate goal of protecting Phoenix in the long-term could be the happy consequence, along with their reunification.
Williams isn’t alive today to answer to the commission for his role in the case, of what he and Sinclair discussed that so convinced him Phoenix could be returned after a “time out” without the young single dad doing the counselling Williams once clearly believed was vital. Or return her without a conditional agreement as had happened two years prior after the girl was first seized and returned.
It’s clear, to me, anyways, Williams understated concerns about Sinclair’s ability to parent when approaching Edinborough to sign off on his work and close the case.
We’ll never know why that is.
We do know Edinborough “winced” when reading his case closing summary at the time and says she continues to do so to this day.
She signed it anyways. Approved his work.
“The work wasn’t very good. It wasn’t enough. It wasn’t good enough,” she testified Friday.
Note how Edinborough didn’t say: “The work didn’t meet standards” or, “I don’t recall.”
The work Williams did was poor. Period. She signed off on it and I shouldn’t have. Period. No prevarication from her — just ownership.
So, then there’s one thing at play. The work was not good enough.
Then there’s the issue of the missing supervisory notes. A mystery.
And multiple issues about the lack of documentation in the social workers’ work.
And then the issue of how a child-protection case can go from one experienced worker seeing it as a “high-risk” situation, to another viewing it as low-risk within a matter of days when the only thing known that had changed was the child being seized.
The list of lacunae goes on and on.
Each problem carries with it a wealth of underpinning issues behind why.
These include, but aren’t limited to: workload/caseload demands, the fact social workers aren’t robots. Some of them weren’t up to the tasks. The fact new devolution policy was likely causing headaches and uncertainly in terms of who was going to be doing what and when and how and where. The fact the clients — truly the heart of the work — each presented different problems which needed to be considered and weighed.
RISK and SAFETY
But Edinborough, to her credit and our benefit, shed a lot of light on what I see so far as the number one systemic issue which led to little Phoenix’s calamity.
(Setting aside for a second she had a despicable mother who kept house with a vile boyfriend).
It’s how CFS, again — in Phoenix’s lifetime — handled the concepts of “risk,” “safety” and assessment of potential future harm to a child.
(Having looked into the topic, one could have a public inquiry based just on this one general issue alone, I suspect).
Edinborough, like most other material witnesses, was asked to comment on the findings of internal and independent reviews conducted after Phoenix’s death was discovered.
One of them, a file review by Rhonda Warren, outlines succinctly the most confounding internal problem CFS likely faced. Here’s the excerpt.
Statements of risk change from low to high without any change in circumstance. Statements of Safety are referred to as Statements of Risk. A family situation may be high risk even if on any given day the child is deemed to be safe. Unfortunately in this case `low safety assessments’ were deemed to be `low risk assessments’ which were not the case. This continuous error resulted in this case being closed numerous times without adequate intervention by the Agency. An Intake worker clearly articulated this problem in an assessment done in June 2003 (note: right before Edinborough took over the file). She states:
“It is this worker’s opinion that it is this attitude [resistance] and disregard for the Agency that has probably resulted in this Agency’s previous termination of services, and not lack of child welfare issues. If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the Agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse issues, and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and or placement in Agency care.” (This is from Laura Forrest’s file transfer on July 27, 2003 — Commission lawyer Sherri Walsh didn’t read this out directly to Edinborough as this section was discussed earlier in the day).
Unfortunately this statement was ultimately ignored once the case was transferred for ongoing service. Based on this case review it is apparent that Risk Assessment is not universally understood by Agency staff. (emphasis in original).
Here’s the verbatim response from Edinborough after Walsh read most of the above to her.
“I think that most of this section is absolutely accurate. I think — I hope the writer of this report knows a lot more about standards and safety, the difference between safety assessments and risk assessments than I certainly did at that time.
However, I think she’s hit the core of what the problem has been, and that’s because risk assessments in particular are based on people’s opinions which are formed by — as I said before — bringing our own values and experience, experience with that client that the risk of it changing every time a worker was assigned was there.
That risk — the risk of the risk changing that’s accurate — and it happened.
I think with the tool we discussed (more on this below), I think that’s less liable for that to happen … the substance of what she says here is absolutely accurate.
Walsh: You recall earlier, a very long time ago this morning, I asked you when an assessment was done as to Phoenix’s safety when she was returned to her father, if there was any concern given to long-term risk of harm at that point.
Edinborough: “Right.” (She earlier testified she wouldn’t expect a social worker in 2003 to speak to the long-term prospect of harm a child may face given all the circumstances learned during a worker’s time with a case — see below).
And that’s what I meant — was were you considering at the moment she was being returned she was safe only? Or were you also considering what her future risk of harm or well-being would be?
Certainly her current safety, the potential of risk is certainly a consideration and factor into that. If we have indeed addressed some of the problems and believe the child is safe enough to return home, the belief is if those changes that were made persist, that the long-term safety of the child, or the long-term lack of risk to the child would continue to exist as well.
Edinborough earlier testified on Friday: A file came to her office from the CFS intake unit with an assessment of risk on it. It was intake came up with an assessment of what the risk was.
When she got the file, her office would pay attention to that risk statement, but her expectation was risk would be assessed by the assigned social worker as he/she worked with the client. “Risk assessment continues to evolve based on the work that occurs.” She said at the time, in ’03, she wouldn’t have seen an intake “safety assessment” as being different from the concept of “risk assessment.” From intake, risk spoke to whatever the “risk might be. It varied.”
For her now (she recently retired from a high-up position at Michif CFS/Metis CFS authority), she says a safety assessment comes out of the (intake computer system) and “risk” is about the potential for future harm.
In 2003, she says the timeframe of the risk assessment looked at the period by which the file was open — “the goal always would be to reduce risk over the life of the file, over the life of the time the worker worked with the family.”
If a file arrived on her desk with high-medium risk, the goal was to reduce/eliminate risk. Harm could be abuse or neglect of a child, she agreed.
For the time your family service worker had the file, did you expect they would consider the child’s long-term well being, govern their actions based on that?
Edinborough: “Depending perhaps on the age of the child, I wouldn’t expect a worker to say everything’s fine now and the infant was safe and then be able to predict – I don’t know how long term … They wouldn’t be able to predict how that child would do at school or what kind of teenager they’d be, so I’m not sure what you…
So then the actions taken on the file would not take into consideration those longer-term eventualities?
Edinborough: No, I wouldn’t expect a social worker to speak to that.
So then, given this realization, what’s changed to address this critical issue?
During the proceedings, a few witnesses have mentioned something called “structured decision making” or the “SDM tool.”
However, Instead of it being a concept, SDM is a computer-based case-management tool used to measure risk not only at the intake level, but also looks at likelihood of future harm for a child.
How it all works exactly will be discussed at length during the inquiries 2nd phase in the new year.
Some child-protection agencies in the U.S. have been using SDM now for many years.
In 2002, North Carolina’s Department of Health and Human Services, Division of Social Services (the Division), implemented an SDM® case management system to assist child protection workers in making decisions at critical points during a child protective services (CPS) case …
The primary goal of the SDM case management system in CPS is to reduce the subsequent maltreatment of children in families in which an abuse or neglect incident has occurred. The underlying logic of the approach is that the most effective way to reduce child maltreatment is to accurately identify high risk families, prioritize them for agency service intervention, and deliver effective services appropriate to their needs.
The objective of a structured approach to case management is to increase the consistency, validity, utility, and equity of decisions at every agency level. Workers complete research- informed assessments at key decision points of a child protection case, and each assessment is designed to inform the relevant decision. This helps ensure that all workers consider the same information when making a decision and that assessment findings inform determinations of service delivery and prioritization. If assessment information is accessible, agency managers can use findings in aggregate to profile their clients, determine service needs and availability, and manage operations. These efforts are likely to increase the effectiveness of the child protection system.