“One of the great mistakes is to judge policies and programs by their intentions rather than their results.” — Milton Friedman
A few weeks back, prior to the resumption of testimony in the Phoenix Sinclair inquiry, the University of Manitoba’s law school held a morning-long public session on public inquiries and their genesis, largely looking at the Sophonow inquiry held many years ago.
Among the four speakers was former deputy Attorney General Bruce MacFarlane.
As I’ve been pondering the inquiry at length, an off-hand comment MacFarlane made keeps coming back to me.
The thing about public inquiries when you’re in government, MacFarlane said, is you never know what you’re going to get.
His words resonate today, because in the drab downtown Winnipeg convention room where Ted Hughes presides over the increasingly contentious and costly proceedings into the role CFS played in Phoenix’s life up until shortly before her 2005 murder, we’re hearing things which, seen in the right light, could shake our Manitoba reality to its core.
And that may not be a bad thing — in fact, this examination of an exceedingly secretive system might ultimately be just what the ER doctor ordered.
But I suspect confronting what needs to be confronted will be anything but easy.
Let’s start with a fairly well-accepted premise about political power and its legitimacy: A government and the systems it uses to exercise its power (policing, taxation and, yes, child-protection for example) are essentially rendered toothless and ineffective if the citizens those systems serve don’t ‘buy into’ them and accept their actions as proper, justifiable and fair.
(To put it more concretely, even the most garden variety city cop reporter will tell you the ‘f**k the police, f**k the courts’ sentiment in Manitoba is not only prevalent but has grown considerably in the last 20 years. Disrespect for police authority and the justice system is high.)
So, let’s recap just a few salient truths we’ve heard so far about Phoenix and her circumstances, and some of the circumstances of CFS from 2000-2004.
Mom and dad, both young and disadvantaged, were each products of the CFS system.
Phoenix was taken into the custody of CFS same child-welfare system at birth.
Dad was considered a “passive resistant” CFS client who wanted to raise Phoenix himself in order to spare her his own childhood experiences of the system.
When dad was offered CFS services in a time of heavy grief, he rejected them for ones he could access from and in his own community.
The CFS system set rules and goals (case plans) for her parents to reclaim Phoenix, but didn’t follow them to the letter.
CFS committed itself to following up with the family, but couldn’t seem to do it in a uniform or consistent manner.
There was confusion of whether the CFS client was Phoenix, her mom, her dad, both or all three at the same time.
The family lived in a severely challenged community where the need for CFS services was always stretched thin.
The personal ‘values’ workers brought to cases directly influenced important aspects of it, including assessments of risk children faced.
Any actions taken by the CFS system’s actors (largely based on presenting circumstances) were hemmed in by legislation requiring that families and kids were to be dealt with in the “least intrusive” manner possible.
CFS agents — namely social workers — were rebuffed, misdirected or outright lied to in many of their efforts to look out for Phoenix when she was not in care (though at the same time, CFS appeared to do little to verify much of the information it was receiving.)
We could take apart and debate and analyze each and every one of the above.
But for today, anyways, lets just start by looking at the concept of ‘values.’
Consider his clearly stated perspective from his past brushes with the system:
“I was coming from a marginalized group of society: low income, partying lifestyle, general distrust of police and the establishment. … “I had no positive experience with police in my youth certainly, or with CFS. I had only known CFS taking children away. Not fixing families only breaking them.”
Also consider another example, the mistrust and resistance to the agency implied in Steve Sinclair’s statement to social worker Laura Forrest after she came knocking on his door in early 2003. He refused to tell her where Phoenix was.
“Then she would have went down there and got up all in their face. I knew she was safe. That’s all that mattered to me. They would have made a different judgment call in their eyes, right?”
“We’ll see about that,” was Sinclair’s resistant reply to Forrest when she told him she’d return and had to see the little girl.
What the above directly implies is the values and work the CFS system performs clashed with those of its clients. Not all of them, for sure, but likely many.
Also interesting is how in Stephenson’s case, CFS and police are linked as being similar entities — as illegitimate actors of the state whose interference is perceived as an intrusive threat and not a benefit, based on past experiences.
But the quandary is very clear: What is CFS to do if the heart of its work — the children and families it’s mandated to serve — don’t believe in what you’re doing and don’t support your right to do it?
How does the system, looking forward, get past the entrenched ‘us versus them’ mentality? Was this also a goal of the devolution process?
It’s a fundamental, if not foundational question. One Hughes will have to investigate if he’s going to recommend realistic ways to better protect children.
In Phoenix’s lifetime anyways, CFS clearly appeared to be a mess.
And today, we’re told the need for CFS has grown, not abated.
The government — where the buck ultimately stops regardless of the bureaucratic CFS authorities system it uses to deflect that reality — has and will likely continue to throw millions of dollars, discretion-regulating technology and staffers at the system.
That ‘solution’ will continue, I suspect, until the point we’re willing to do what may seem impossible: Confront our issues and prejudices, settle long-standing scores we have with each other and move past them already. Find a better way.
But to reiterate where we started off: We don’t know what we’re gonna get.
The death of any child, no matter the circumstances is horrible, and to see one murdered, simply unspeakable and intolerable. We can all agree to that.
From that baseline, we have our work cut out for us.
That’s clear, and will become even more so in the hard days ahead.
“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.