Phoenix in hindsight: Two Reviews


(Phoenix Sinclair)
(Phoenix Sinclair)

Not a ton to say today, but simply wanted to alert PSI followers to the fact the good folks on the inquiry staff have put into the public record in full a number of different reviews and reports which were conducted into Phoenix’s death after it was discovered.

Reading them top to bottom gives you a good sense of the serious issues Child and Family Services and their clients dealt with in the pre and just-post “devolution” phase, and, naturally, the quality of case work and decision-making conducted in Phoenix’s sad case.

What I’ve found most interesting is the marked difference in tone between the two reports.

One was conducted by a commissioned child-protection expert from Ontario, Andrew Koster, and co-written Billie Schibler.

The other, also written by a veteran social worker — Jan Christianson-Wood — was authored for Manitoba Justice/ the Medical Examiner’s Office.

Read them and you’ll see what I mean about tone. Koster’s, while insightful, appears far less blunt in assessing the quality of CFS work.

In any event, it’s fascinating stuff — rare and in[hind]sightful looks at Phoenix’s case and her interactions with the CFS system.

It also bears remembering that these reviews were not shared with workers involved in Phoenix’s case. By and large they only saw them — and then only in bits — in their preparation for the inquiry.

Virtually all, to my memory, said they wished they had been.

I tend to agree they should have been disclosed to them — and to the public too, at least in some form.

More to come on this at a later date.

Reliving unnecessary horror, or why McKay’s sons should not have been called

(The bland-looking home where Phoenix Sinclair was tortured and murdered)
(The bland-looking Fisher River home where Phoenix Sinclair was tortured and murdered)

I hear you when you say your family’s broken … what this has done to you. — Commissioner Ted Hughes

There was absolutely no need for the Phoenix Sinclair Inquiry staff to put Karl McKay’s sons on the witness stand today.

And even having his ex-wife (a McKay domestic-abuse survivor) testifying today was questionable, save for the fact she says she notified Chid and Family Services of potential abuse to Phoenix long before the McKay-Kematch house of cards coming down on top of them in March 2006.

For the inquiry’s sake, she needed to be questioned on this point. That’s fair game.

But the fact there were few cross-examination questions for the McKay “boys” from non-inquiry lawyers [In fact not a single query for child the elder] is telling.

This is just my respectful opinion: There was virtually nothing McKay’s sons had to offer this inquiry which couldn’t have been tendered through affidavit evidence, sparing them the stress of reliving in public the horror they’ve experienced and already testified to in court in 2008.

This became clear to me pretty quickly. These are two now-young adult men who’ve been rocked to the core by what they’ve been forced to live through, through no fault of their own.

And the one likely the most directly affected, McKay son the younger — the eyewitness to a lot of the horror Phoenix went through in a supposedly “tight-knit” Fisher River community which apparently failed to notice she was even around — was clearly terrified by the prospect of being pilloried in the public eye for not speaking up sooner about what he saw than he did.

“Can I make a statement,” the 20-year-old asked at the conclusion of his hour-long direct examination by commission counsel.

Yes, said Commissioner Hughes. The young man had a message for the media in the room — of which there was more than has been usual.

Can I ask you reporters – don’t try to make me sound like the baddest guy on earth?

I read the paper, you guys make it sound bad – you guys make it sound horrible. I couldn’t help it, man.

That’s like the only thing I ask — just don’t make it sound like I’m really bad and terrible, Because I already feel bad. Now that I’m older I feel, like, so terrible and it’s bad enough that you guys are bringing this all back to me and I got all these little memories flashing in my head.

I just want to forget all that.

And without a doubt, we should be doing everything we can to help these young men get past this. Commissioner Hughes even graciously pledged to McKay’s ex to help as much as he could.

What child the younger witnessed basically ruined his life, he said.

“Where do I start?,” he asked when lead commission lawyer Sherri Walsh queried how the Phoenix incident has affected him:

“I’m a pretty fucked up person now. … used to be a good kid … all of it’s gone like that (he snaps his fingers a few times).” He said he turned to drugs, booze and crime to “block out what I seen.” “(I’m) trying to get my life back together,” he told Hughes. “(It) made me a terrible person,” he said.

His brother’s no different: “I think it made me more like my dad, because I get — when I rage, I can do some damage,” he said.

They were just kids when Phoenix died. Not paid social-work professionals or community vanguards.

Mere children who came from not very much and now saddled forever with the burden of what their odious father did.

The younger son won’t even call him his father, saying he prefers “Wesley” or “Karl.”

If there was one thing their testimony did accomplish, it was to further cement for commissioner Hughes the culture of fear they, and others in their positions, lived in.

  • Fear of Karl McKay, their violent and vengeful father (their dad) — and what he might do if they ratted on him.
  • Fear of the child-welfare system [both boys were apparently scared when Intertribal CFS workers turned up to ‘rescue’ them in July 2005]
  • Fear of the media and public scorn — of being cast as villains in this horrific tale.

It’s been many torturous weeks since Rohan Stephenson testified at this now-$10-million inquiry.

But it was his words that really gave the most insight into what the major problem was when it comes to considering Phoenix’s case.

“So I was a liar, and (CFS) were incompetent and 15,000 other circumstances all came together and now Phoenix is dead,” he said Dec. 6.

The more I reflect on this, the more simple dissecting Phoenix’s pathetic voyage through ‘the system’ becomes. It really boils down to this:

CFS can’t do its job if people won’t come forward with information, for whatever reasons — including their fear of ‘the system.’

At the same time, when CFS was given information about Phoenix, it failed to rate much attention or urgency until it was too late.

Putting McKay’s sons on the stand today, in my humble opinion, takes us really no further in solving this dichotomy.

We knew all along what they had to say, and by now, we probably instinctively know what it is we’re really confronting here.

We’re no further along today as a result of McKay’s sons’ testimony.


Bits at the end of a long, newsy week Part 1 — Phoenix

Screen Shot 2012-12-01 at 8.13.14 PMFrom the stunning turns of events in Boston and Texas to, locally, the provincial budget and the government’s plan to hike of the PST as of July, it’s been a hell of a week for news.

(Great blog on the budget here, BTW. h/t Cherenkov. I appreciate honesty too.)

But on top of emerging craziness, the Phoenix Sinclair Inquiry resumed witness testimony after several weeks off, partly due to the delay caused by perceptions of conflict.

And while the evidence heard this week was at times disturbing and concerning (Cpl. Rob Baker’s testimony, along Alison Kakewash’s hit me personally like a ton of bricks), I’ve been turning my mind more often lately to what Commissioner Hughes could be making of it all.

As we approach what’s sure to be the gloomy end of Phase 1 on Tuesday or Wednesday, it strikes me there are two nuts-and-bolts recommendations Hughes could make today to fulfil his mandate to help better protect Manitoba kids.


This been a frequent underlying issue at the hearings so far. An old Child and Family Services database (CFSIS) limping along. Lack of consistent Internet access for CFS agencies outside major centres. That lack of infrastructure leading to a ‘why bother’ kind of attitude from workers, leading, in turn, to a lack of due diligence in doing things like Prior Contact Checks — the very thing which could have “changed everything” in Phoenix’s case. I’m reasonably sure Hughes has turned his mind several times now to the technology issue. There’s no reason in this day and age all communities shouldn’t have proper access to the CFS computer system. We can put infrastructure in remote areas to ensure VLT/Casino data is accessed daily. Surely we can do the same for child-welfare services.

Last fall, the Auditor General specifically noted that the province has been slow to implement a number of key recommendations dating back to a 2006 CFS audit — and electronic case management and tracking was among them. So obviously the powers that be are aware of the problem.

The Auditor General noted a plan to completely replace the CFSIS system stalled in 2009 and by time of writing hadn’t had an update:

Screen Shot 2013-04-20 at 6.34.47 PM
(From Fall 2012 AG followup report)

Screen Shot 2013-04-20 at 6.35.06 PM

Inter-departmental and external agency information sharing

This is a fundamental issue. And when you have a veteran cop like Cpl. Baker saying sharing between various government agencies — such as CFS, Employment and Income Assistance, Health and police — could be better, it probably could be better.

Instead, we’ve heard several times now how people’s fears at violating privacy and health privacy legislation has led to slowdowns in the investigative process. Baker said RCMP, his police service, has no issues quickly sharing certain information with agencies conducting “like minded” investigations — but found when investigating Phoenix’s homicide there was pushback from CFS when he hoped to access sealed “child in care” files held by a CFS agency. Luckily, EI investigators were ready and willing to co-operate and set up the ultimate “sting” which exposed Kematch and McKay — and Phoenix’s death — nine months after it happened.

Workers investigating a child-protection case shouldn’t be hamstrung by having to invoke “magic words” to glean information quickly out of other agencies who may have valuable data, and vice versa. Any abuses could be ferreted out with a strong quality-assurance program. Information is like oxygen to investigators of all stripes. If we believe they are working towards valuable goals [like the safety of at-risk kids], they shouldn’t have to fight for information.

But it’s a contentious issue, for sure. Even police agencies can’t figure out a way to co-operate when it comes to data sharing, as this (to my mind, sad) report out of Alberta suggests.

Queensland, Australia child-welfare inquiry

Interesting (350-page) read below:

A massive child-welfare inquiry in Australia is about to wrap up with a final report from its commissioner by June, likely earlier. What’s relevant is how many issues there are echoed over here, particulary the concerning rise in the number of kids being taken into care, largely because of neglect, not abuse.

The website is a model for future inquiries, I feel. It’s easy to find the disclosure, they took it on themselves to live-stream it, and staff even communicate with the public via social media. As well, people are encouraged to participate by sending submissions to the commissioner.

While I’m not knocking the effort for Phoenix’s inquiry — communications staff have bent over backwards at times to ensure media have been given proper access — but perhaps a few more of the $9.6 million we’re currently spending could have gone into making the proceedings and website more accessible to the public, virtually all of whom can’t make it to take in the hearings during working hours.

The design is a bit dated — and it’s very difficult to navigate the disclosure which has been presented, unless you note page numbers as you go along.

Here’s the recent discussion paper from the Australian affair. I’d love to foster a discussion about it with readers, so chime in in the comments and we’ll make it happen somehow. Perhaps through a live blog of some kind.

[Part two of this post will look at a few other non-PSI things I dug up this week, including an interesting tale about the infamous Darrell Ackman, AKA Mr. JetzTV]


Late edit: I just wanted to point out some things which have been picking at me, relating to the internal CFS documents tabled at the inquiry.

Look closely at this, for one example:

Screen Shot 2013-04-20 at 8.05.15 PM

This was the file closing of Shelly Wiebe from December 2004.

Notice how her surname is typed one way — IE —

But her signature states it’s EI.

That’s odd, no? Who misspells their name in their signature?

Here’s another oddity, from this week’s report from Intertribal CFS.

Screen Shot 2013-04-20 at 8

Why is it that it’s the same report  — just one page apart (you can see the page break) — but the formatting in terms of spacing is so different? It’s weird.

There’s been a few other instances of documentary oddness. I’ll add them as I come across them.


Phoenix Inquiry: The Trigg memo and a history lesson

Screen Shot 2012-12-01 at 8.13.14 PMThe inquiry this week is moving further into its exploration of what was going on behind the scenes within Winnipeg CFS from 2001-2004.

We’ve already heard a bit of evidence from Dr. Linda Trigg, who at the time was the CEO of the agency at a time of massive systemic change, coming on the heels of a separate restructuring which was never fully completed from the late 90s.

Trigg has already told us of a loss of community contact between front-line social workers as well as talked about how funding was in short supply — or that willingness to hike funding to operations as they were in the wake of the incoming ‘devolution’ wasn’t on the table.

Workloads were very high, as was anxiety and uncertainty about the changes underway.

The inquiry was shown a memo she wrote to familiarize the new interim Winnipeg CFS board with what was going on internally. I present what’s available here.

Pay close attention in it to her comments on the troubles within the intake unit and how it is to be restructured as part of the devolution process.

Also, note the following chart on levels of experience within the units and the relative youth and inexperience on the “key and front-line” family service positions. Staring down massive uncertainty, workers with experience appeared to find “safe haven” in other areas of CFS. Seniority was the main means of transferring, meaning Trigg was unable — as she says she was told — to simply “move” people to suit the agency’s needs.

Screen shot 2013-01-28 at 7.59.45 AM

When you’re done with that, take a few minutes to familiarize yourself with this 2003 expert review of the process — and more importantly — the history of the devolution (AJI-CWI) implementation process. The history provides the context.

Keep your eye on passages referencing funding and expectations.

“However, the critical issue is funding. There is an expectation among service providers that new funding will be needed in order toenable more than a tokenistic gesture towards the development of a new service paradigm for child and family services. At present, the Province expects such a shift in services to occur through the reallocation of existing resources.”


Phoenix Inquiry: Watching the watchers, or, odd logic part II

(Samantha Kematch)

Dan Berg had a lot to say today. At times, words flowed from the former Winnipeg CFS assistant program manager’s lips in a hard-to-get-a-bead-on  torrent.

Many times, Berg answered whatever question was lobbed his way by splitting his response into several parts, making it hard to parse out exactly what he meant.

Berg, in 2003-2005 was the supervisor tasked with supervising workers in the Crisis Response Unit and Diva Faria, the unit’s go-to supervisor. To be fair, he also had a number of other key CFS programs to monitor under his watch, all housed in the same drab Portage Avenue building.

As was usual, the commission lawyers took their time building the groundwork of evidence under the witness, setting out for Commissioner Ted Hughes their history with child-welfare in Manitoba, the level of training they received from CFS and other salient issues, such as their knowledge of and reliance on provincial and CFS program standards.

Berg’s evidence today is important in the respect that the public got a glimpse of how the watchers — the CFS supervisors dealing directly with case workers — were watched by senior management like Berg in Phoenix’s day.

We learned through him that when he was hired into the role he wasn’t offered any specific training to do the job, one that he described as a “huge, huge responsibility, a big job,” Looking down into the well, we’ve already seen how the workers and supervisors Berg was overseeing, likewise had little specific training from CFS when taking on their roles. He denied under cross examination he wasn’t a good fit for the role.

Most, if not all CFS workers and supers we’ve heard from, were provided no training in the standards or risk assessment when they started  — some not until years after Phoenix’s murder.

That’s not to say they weren’t capable employees — but it helps us set a baseline of expectations for what we’ve been hearing, maybe.

Through Berg, we learned a number of salient things, including that he, as one of three head honchos within the Intake unit in his time there, didn’t appear to find any issues with the way CFS workers handled Phoenix’s case.

Unlike many of those already called, Berg had the benefit of reading the files in full in September 2006 as well as reading the complete external/internal review reports done in the wake of Phoenix’s death.

“With the Phoenix Sinclair matter, were any performance concerns brought to you attention with respect to any of the workers?,” Commission lawyer Derek Olson asked him.

“Not at the time,” he said.

“Based on what you’ve reviewed, would you have expected anything — anything in those documents to raise performance issues with respect to the work done?

“There’s nothing that I’ve read that jumps out at me to cause me to believe that if I.. was a manager (evaluating) performance issues that I would discipline staff over? I’d say ‘no’ to that,” Berg said.

Fast forward to the afternoon session, when Olson and Berg’s exchanges appeared to take on a different tone. Nearly heated at some points.

The touch point came after a long series of questions about response times and how those were determined. Olson asked Berg if he was ever involved in the auditing of files. He said if serious client complaints came in he would get involved if an “independent” review was required, or, he suggested if it appeared clients involved in custody battles were using CFS as a method of comeuppance

In terms of formal auditing of workers’ files, Berg said a curious thing about the Crisis Response Unit, which has routinely been described as the place where the most serious and urgent matters got the most attention.

Files were audited “not so much at CRU, because CRU was such a short-term service,” Berg said. “Auditing probably didn’t make much sense there.”

That’s curious in the sense that again we’re seeing that the unit where the most key, sometimes life and death decisions, appeared to merit less, not greater oversight.

We saw this theme play out in the recent evidence of Berg’s CRU supervisor, Diva Faria, where she indirectly spelled out how oversight seemed to increase as files and families became more stable and moved on to “tier 2” intake or family service units.

It’s more odd CFS logic, no?

In any event, Berg went on to say there was no quality-assurance program in place at Intake when he was there. He says that there were some programs which came out of a connection to people in the quality assurance division of CFS.

“We didn’t have any other individual attached to us who was doing quality assurance,” he said.

Olson then moved directly on to Berg’s assessment of what’s been pointed to as a central failing of Phoenix’s case: The fact that two workers went to her mother’s home to investigate a non-specific claim Samantha Kematch was abusing her daughter and left without seeing the child. They went back to the office and Zalevich recommended the file be closed after not noting any child-protection concerns.

“That’s correct,” Berg said when asked if he knew that had happened. He then took time to review CRU worker Christopher Zalevich’s report in full. (36928).

I’m presenting the verbatim exchange of questions and answers on ‘the visit’ below.

But before going further, maybe you might do the same and look over the report yourself.

Screen Shot 2013-01-23 at 11.24.52 PM
(What Zalevich was looking in to)
Screen Shot 2013-01-23 at 11.21.11 PM

Derek Olson: I don’t think there’s any dispute or controversy over the fact they did not see Phoenix Sinclair at this time.

Dan Berg: That’s correct.

O: The allegation that they were there to investigate — I think (it was) referred to a non specified abuse allegation.

B: The original caller said she believed this child to be abused but couldn’t provide any kind of information about the physical address of where the family lived or identifying information about the kind of abuse allegations themselves.

O: I think she said abuse as well as locking Phoenix in the room.

B: That’s correct.

O: So based upon that, Mr. Zalevich and Mr. Leskiw are going out to determine if there’s anything to this, right? This abuse concern.

B: Yes.

O: Generally speaking, it seems fairly basic that, in a case like that, a social worker would see the child who’s the subject of an abuse allegation. Is that fair?

B: General practice would be that you would see the child when you go out on a protection investigation.

O: And that’s not — I don’t want to use the term best practice — because it’s pretty basic, isn’t it?

B: Well it was in the Feb. 3, 2004 CRU minutes that CRU supervisor Faria outlined it very clearly when you’re conducting assessments, you should be conducting assessments by, wherever possible, seeing the child and seeing the family, and seeing the residents. And that was fairly accurately put as to what the expectation at the time was.

O: Especially when you’re dealing with possible abuse?

B: I think the fact that you’re out there on a protection investigation would suggest that those are things that you want to check on.

O: I know you don’t like the term ‘common sense,’ but it seems tone fairly common sense that if you get a report a child is being abused, you’d see the child.

B: You’d want to start with the parent and talk to the parent and you’d want to do all the steps that [Leskiw and Zalevich] did. You indicated yourself — sometimes assessment, if you believe it’s any validity to the report itself. And at the end of the day it might have been a more full and complete assessment had they seen the child.

O: My specific question was that it was pretty common sense that you’d want to see the child who’s the subject of an abuse allegation.

B: It would have been advisable to see the child.

O: [Barely pausing]I mean, here you have the mother who’s actually the one whose — she’s the accused abuser — that’s what the concern was.

B: I really didn’t see anything in the record that it’s the mother who is the abuser. I may have missed it, but I don’t think I saw that.

O: Maybe just helpful to pull it up on the screen – 36927 — under the presenting problem — it says that ‘this person told the source of referral that she suspects that Samantha Kematch was abusing her daughter, Phoenix, and that Samantha may be locking Phoenix in a bedroom.’ So that’s what I said before was correct, that it’s Samantha Kematch who was being accused of abusing her daughter. So in that case, what would you say about relying on Samantha Kematch in terms of determining whether or not there’s anything to this allegation?

B: Well I think you have to start with Samantha Kematch because [inaudible] abusing her daughter and I think they did start with that, they did talk to her directly about that, she denied that. She was open to them about yelling at her daughter, previous to that, recently previous to that. And they did talk about the lock on the door, and she confirmed to us that a bedroom she shared with her and her daughter — there was a lock on the door and she appeared to be open and responsive in regards to removing the lock, it being a fire hazard, a fire danger. In regards to seeing the child, it’s clear — they didn’t see the child.

O: They didn’t see the child, right? And not seeing the child in this case, when you look at it as a supervisor — was that appropriate?

B: It’s hard to say if it was appropriate or not. Best practice would have been that you would see the child. That would have been best practice.

O: But wouldn’t that have — just be basic social work practice? That you’re checking on an abuse allegation where the child — wouldn’t you see the child as part of it?

B: It would have been advisable to see the child.

O: So not seeing the child here, was that, was that appropriate? I mean, you’re a supervisor so you know whether or not …

B: Well, if you look under the standards in regards to protection investigation, the standards state that we’re to investigate a protection investigation within 10 days and see the person or the family — and, I, by our standards, they would have met the standard — they were out there before 10 days they did see [inaudible] they did see the family. They didn’t see the child.

O: [Again, barely a pause] Are you suggesting now that the standards are actually saying it wasn’t necessary to see this child, or a child under the subject of an abuse allegation with that?


O: [Cuts him off] I mean, I want your understanding of what’s required.

B: I guess we’re having to discern a bit between whether this is a protection investigation or an abuse investigation (Note: ‘abuse’ investigations had certain requirements before they could be officially called that at the time].

O: I’m not talking about investigation, just determining whether there’s anything to this allegation of abuse. They substantiated that the door was locked — there was a lock on the door, so that lends — I would think that would lend some credibility to the caller — going out with the information, the facts that you’re aware of, are you suggesting that the standards say you wouldn’t have to see the child?

B: I’m trying to help clarify a small but important point. That the standards are different if this situation is viewed as a protection investigation verse [sic] this is viewed as an abuse investigation. There are different requirements. There are different timelines and there are different expectations of how you follow up and who you need to see. And at the end of the day, it is, I believe, from reading all the information that they viewed this not as an abuse investigation, but that they viewed this as a protection investigation. And based on that determination, they’ve actually done what the requirement was under the standard at that time.

O: Were they at a point where they were able to decide whether this was an abuse investigation or a protection investigation?

B: That’s a question probably better answered by the worker and supervisor, but it would seem to me that when they did their involvement, wrote it up, they believed they did not have any protection concerns and as such, the worker made the recommendation to close off the case.

O: Right, that’s without seeing the child.

B: That’s without seeing the child.

O: So before we get to the recommendation to close and they’re closing it based on that they don’t think there are any concerns, but the goal is ultimately to determine whether or not the child is safe.

B: That’s one of the goals.

O: To do that, don’t you have to see the child?

B: I said it would have been a more complete assessment had they saw the child.

O: And when it comes to the standards, you’re not saying that there’s any question in your mind that whether or not the standards would require seeing the child.

B: I’m saying to you that if it’s a protection standard they met the requirement. If it’s an abuse standard that it would it be viewed on this being abuse, which I’m not saying that it was. The caller said it was abuse, it was very non-specific in outlining abuse related concerns. But the expectation in the standards — if it was viewed as abuse — is you would have had to see the child, you would have had to see the other children in the home, you would have had to see the parents or care providers in the home, you would would have to see the offending part if you thing the abuse had happened with the approval of police and there was a — and if it was viewed as abuse by our agency, there were 14 other requirements in the abuse program they would have to follow.

O: When these workers went out, they didn’t know if it was abuse or not. All they had was the allegation that was made, right? Right?

B: Well, they had the allegation that was made and then their involvement in their follow-up interview with the mom and their observations of her with the child [Kematch’s baby, not Phoenix.]

O: And the mom who is accused of abuse.

B: Yes. You pointed that out.

O: Just based on those facts, whether you characterize it as an abuse allegation or a protection concern, just based on those facts, isn’t the first thing you do — to find out whether or not there was anything to the concern, the abuse allegation?

B: That would have been invaluable and it would have been a more complete investigation.

O: [Long pause] The determination that there were no child-protection concerns is something that was made without seeing the child.

B: That’s correct.

O: Is that determination  — is it even possible to make that determination without seeing the child? In a case like this?

B: Is it possible? I think we see an example here where that’s indeed that’s happened. That was a recommendation from the worker, and it was reviewed and signed off by a supervisor.

O: We know what happened — but you as a supervisor, a supervisor of a supervisor and you see this — would you be able to say the child is safe? There aren’t protection concerns?

B: You know, I have to answer that in kind of two ways. The first way would be: There were two staff that went out, one of the workers had 7 months experience in the abuse program. The other worker that went out with the first worker had 15 years of experience, most of that with the Crisis Response Unit — was a very experienced, seasoned CRU worker. And at the end of the day, I believe that the supervisor trusted the combination of the information from the two workers at the end of the day and made the decision to close the case off — due to ‘no protection concerns.’ I do not know what the workload related issues were going on at the time. I don’t know ..

O: [cuts him off] But, you’re not suggesting that workload should ever impact decisions — as to whether or not an allegation of abuse was investigated. And that would have a part in it.

B: Again: back to this being a protection investigation rather than an abuse investigation. In a protection investigation, there have been times, when it it really busy and you are having to make choices out there of what you can and can’t — what you can and can’t follow up on. That some of those difficult choices are made, there are times when children aren’t seen. It’s not our usual course of action, or what we believe that we want to do — it’s certainly not what we had in our minutes and reflected in our expectations.

O: The minutes you’re referring to, where its recorded that if there are child protection concerns, workers should get out if possible to see the child.

B: That’s correct. See the child and see the family and the residence.

O: Right. Those minutes were from Feb. 3, 2004.

B: Yes.

O: That was an issue and that was something that workers were made aware of.

B: Absolutely.

O: And that’s not specifically talking about abuse concerns, it’s just where there’s a child protection concern.

B: That’s correct.

O: That might be where someone leaves power tools out and the child is at risk, right? It’s pretty broad.

B: It’s pretty broad.

O: And abuse is a little more narrow than that. So … you have to look at the circumstances as the they present and make your determination based on that.

B: That’s correct.

O: And here we have the two workers at the door, who have the ability — when you say workload – they’re at the door at the time …

B: Yes.

O: … They could have asked to see Phoenix at the time.

[Draws an objection from Berg’s lawyer, Kris Saxberg, as Zalevich testified asking to see Phoenix was something he would have done. This is true, Zalevich did testify he would have asked if Phoenix was there based on Kematch’s responses and his usual practice.]

Olson: We don’t know what happened at the door other than what’s recorded in the note right, Mr. Berg?

Berg: I just have the record that’s before me.

O: And as a supervisor to supervisors, that’s what you’d have, right?

B: Yes, sir.

O: If you look at it, knowing what you know today and that’s based on what’s in the note, would you have expected the worker to do more in terms of asking to see the child? Record whether it did?

B: That’s a difficult question. In [inaudible] workload. And at the end of the day, If I had a seasoned, experienced CRU worker who went out with one of my more junior staff who had 7 months experience in the abuse program, and they met with the mom. And they did discuss what they did, and at they end of the day that they were both of the opinion that they — that there wasn’t validity to the source of referral information when it came in, I would — I’d make exactly the same decision that the supervisor did.

O: As a supervisor, when you look at the document, the documenting here, the recording — there’s nothing to indicate what questions were asked of Ms. Kematch. Wouldn’t it be important to have a record of whether or not Ms. Kematch was co-operating with a request to see Phoenix, or whether she said Phoenix was at day care or at school — something setting that out clearly?

B: You’re asking me to respond as if I was the covering supervisor for that day.

O: Exactly.

B: And as the covering supervisor that day I might have had those questions. I might have had that — questions about what efforts they made to see the child. I do not know what was on their plate that day in terms of workload and other things that were happening and at the end of the day, they had options, if they wanted to. They could have taken this case, said, ‘we’ve gone out and done what we need to do — we’re going to send this back up to Tier 2 intake — that was an option. The second option that they had — as this was a very difficult time for all of us at Winnipeg Child and Family. So many family service units were closed, so we had developed a program at 835 Program … called it out ‘CRU diversion program.’ … they had two options that they could have, at the end of the day, chosen to have sent this case to. They could have said: ‘We want to have this child seen.’ those options were open to them. They believed that there were no protection concerns and so in their professional judgement, they made the decision to close the case. Wasn’t that they didn’t have options. It was that they believed there were no protection concerns and were satisfied with the information provided by the mom.

O: And you as a supervisor …

The Commissioner: Mr. Olson, I think we’re just going around in circles now.

[They move onto another area]

Funny, Mr. Hughes hasn’t made any of his findings public yet.

But he sure hit the nail on the head with his comment capping off that lengthy exchange.

Around in circles indeed.


Phoenix Inquiry: The odd logic of ‘concerns’ and oversight

(Phoenix Sinclair)
(Phoenix Sinclair)

Trying to figure out how Phoenix Sinclair managed to slip through the cracks of Manitoba’s child-welfare system and wind up murdered by a mother who was a walking red flag for trouble?

It’s actually very simple, really.

But, like most simple things, it’s incredibly complex and nuanced.

As we’ve seen in the last few months, Child and Family Services is an incredibly complex beast.

How it does things is complex. The problems it contends with are more complex than CFS is.

I worked with a woman once in another field before becoming a reporter. She was very sweet and well-meaning.

But under stress, she was an absolute nightmare. Under stress, her priority was to get whatever tasks she had to accomplish out of her face as quickly as possible, no matter if they were done appropriately or with due care or attention or not.

I chalked it up then, as I do now, to human nature. That’s just how she responded to having multiple — and sometimes competing objectives to fill — and had no time to accomplish them and make everyone happy.

Clients would leave nonplussed, but to my colleague, it was all good — she felt as if she did her job.

Fast forward to today, when the last CFS supervisor to eyeball Phoenix Sinclair’s case spent an agonizing second day on the witness stand, called to account for a case she had no real reason to give too much attention to in March 2005, for reasons explained below.

The final protection file opening and subsequent closing for Phoenix appeared doomed from the start to not produce any meaningful intervention by CFS.

And in hindsight, we can judge and condemn all we want, but the reality is, taken in the context of the CFS crisis-response system which existed back then, Phoenix’s case likely got more attention from the system than it might have otherwise, strange as that is to suggest given the outcome, I know.

Let’s start from the top:

That March, CRU took it’s usual hefty number of referral calls — 1,311 — following a February where there were 1,342, which resulted in just a handful of the available CRU field workers doing 529 investigations over the 20 or so business days available to them.

At that time, the whole “walk of shame” issue (the process of the Intake Unit — the squad which was supposed to take files from CRU where follow up was needed — was rejecting files and sending them back down despite policy indicating that wasn’t to happen.)

The math worked out today laid bare the grim fact that workers doing field calls — workers like Richard Buchkowsi, Christopher Zalevich and Bill Leskiw — were basically given 1-1.5 hours to work on each of the five new files they would be handed each day.

Nobody appeared to have any training in the provincial standards, and there also appeared to be several schools of thought on which standards actually applied at the time. There were older ones and newish “draft” ones floating around. In the absence of that, Faria says “best practice” was the standard — trying to meet “optimal outcomes” for kids given the myriad of challenges her unit faced.

And that’s just a hint of the structural/internal stuff going on, just months before Winnipeg CFS went “live” under devolution (although the exact impact this sea change had on the CRU/Intake procedure has yet to be fleshed out in full).

Now, moving to the actual work on Phoenix’s case:

March 5 (a Saturday): The call comes in to the after-hours unit (AHU). A CFS foster parent gives second-hand information alleging Phoenix was being abused and possibly locked in a room by Samantha Kematch. The source who made the call to AHU suggests she was met with argument after refusing to divulge who was giving the information. She also disputed whether call-taker Jacki Davidson captured the full spirit of their conversation.

In any event, the investigation ball then got rolling with these eight sentences crafted by Davidson:

“Spoke to an ex foster child today. She refused to provide me with the person’s name. This person told (the source) that she suspects that Samantha Kematch is abusing her daughter Phoenix… (source) does not have any details as to what this alleged abuse might be. Also this person suspects that Samantha may be locking Phoenix in her bedroom. I explained that we need to speak directly to (the informant), but despite being an agency foster home she refused to disclose the name ….  does not have an address or phone number for Samantha other that she lives in apartment one beside the Maryland hotel. I explained that without an address we will be unable to follow up. The last address on CFSIS is on McGee. For consideration by CRU.”

Davidson also cut-and-pasted a file history on Kematch and the case (a practice, no surprise, which is now forbidden). The history missing key information from January 2004 and December 2004 past interventions — One of them possibly because of a computer glitch. It also contains no mention of ‘Wes McKay’ for whomever gets the file to follow up on.

The file Davidson worked up is also, for some unknown reason, missing a routine “Safety Assessment” form which would tell the CRU worker how quickly they should respond.

The file sits until Monday morning, when supervisor Diana Verrier passes it off to worker Richard Buchkowski. Buchkowski doesn’t hesitate to act, believing the case to be a “high priority” to look into. He gets right on it, the file shows.

He calls welfare, which for some reason has no record of the family. His next call is the Winnipeg School Division, which nets him an address. He then proceeds to go to Kematch’s apartment twice that day but couldn’t get in. (see Sunday’s blog).

He goes back to the office and recommends the file — now 48 hours old and reaching the expected shelf-life of files in CRU — be passed up the chain to intake for them to look into. That’s their job — and it seemed to work just fine in January 2004 and January-February 2003 when intake workers followed up.

Intake, however, rejected it. Nobody knows why — or at least they’re not saying — but heavy workload is clearly an influence.

The same day Buchkowski and Verrier say the file should go upstairs, Diva Faria gets the file back and hands it off to Zalevich near the end of his day. It’s unclear why, but it sits for another day before he heads out to Kematch’s home with Leskiw.

One thing was clear, and Faria admitted it freely: This was a child-protection investigation.

Faria said in her testimony she had the following expectations of workers as their boss (not an exclusive list):

She expected Zalevich, the primary, to review any available information on Kematch and Steve Sinclair’s cases which was available to him on the computer (he doesn’t have appeared to). Leskiw, she said, was a more experienced worker who she expected would step in and “redirect” Zalevich if he missed something important (Leskiw denies he was really there for anything but to preserve safety in case things got volatile or an apprehension was warranted). Faria expected workers to prepare their own case histories, she testified. (Zalevich worked off the incomplete one as written by Davidson. Leskiw says he knew nothing of the case).

As already made apparent in several reports, the workers show up and Kematch won’t let them in. They instead meet with her outside her door in her building’s tiny hallway so they can speak privately. She effectively blows off any abuse, admits to having a lock on her door and they caution her about it. She shows off her healthy baby and declines services. They leave her a card.

Zalevich and Leskiw return to the office. Zalevich says he and Faria discussed the case and she said it could be closed despite the fact Phoenix wasn’t seen by him. She can’t recall any discussion or testify to anything beyond what’s in the file notes.

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Nevertheless, as we see, Zalevich typed up his file and recommendation to close it, saying, “workers did not note any protection concerns“.

Faria signs it and the file is closed.

There’s huge questions which were left hanging.

The most important of them being: How does it compute that there’s an abuse allegation and workers left without seeing the child and then state there’s no child-protection concerns?

The workers didn’t go in the apartment or see Phoenix’s living environment or examine the lock on the door, so how can there be a finding they noted no protection concerns? Phoenix, it can’t be understated, was four years old and not in school at this time.

Why does it matter that they “did not note” any protection concerns? Is the question to be asked not: What efforts were made to substantiate or disprove the allegations?

Apparently not.

And as a supervisor, what efforts did Faria make to look the file over, to question what work that been done? She testified she would have been trying to ensure workers were following “best practice.”

“Yes, if it’s achievable based on the organizational and systemic challenges,” she said.

And, like it or lump it, those challenges were real within CFS.

And there was work done on the file — done by a unit that shouldn’t have really had it in the first place.

In many ways I think what Faria was trying to say in a lot of her answers was that the system, at the time, was engineering paths to failure.

But there’s no getting away from the fact that it was her oversight on the file which is why she was in the witness chair answering questions.

But it was really one of the last queries — from her own lawyer, Kris Saxberg — which, to me, underscored what’s really going on here:

“I took down (from your earlier evidence) — you indicated if you were not able to determine there were child-protection concerns then you would advance the file (up to Intake). Is ‘not able’ to identify child protection concern similar or different than not having child-protection concerns?”

“If you’re not able, you don’t have any child-protection concerns,” Faria replied.

So there you have it: In the odd logic of CFS circa 2000-2005, you can’t be expected to find what you’re not looking for.

On the flip side, Faria, like Zalevich, shouldn’t be blamed for being put in a situation where failure seems like an inevitable outcome.

Intake should have taken the file. I’m hoping we find more about why they didn’t.

(CRU STATS from 2002 —call levels stay roughly the same through the years)
(CRU STATS from 2002 —call levels stay roughly the same through the years)

Will add more of the CRU statistics disclosures as they are posted by the commission. I can say that from what we’ve seen, referrals stay consistently above the 1,000/month as time goes on.

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Phoenix Inquiry: What the workers saw


For the bulk of last week at the inquiry, we heard much testimony from the two workers who went to Samantha Kematch’s McGee Street apartment on March 9, 2005, and spoke to her in the hallway outside her door after she denied them access.

They were there to investigate Kematch for her potential abuse of Phoenix and look into the fact she may be locking her in a bedroom.

They left without seeing Phoenix — and may not have even asked — but “warned and cautioned” Kematch (the terminology used is so curious) about locking the four-year-old in the room.

Here’s CFS worker Christopher Zalevich’s summary of that visit:

(Zalevich's summary)
(Zalevich’s summary)

Just for the sake of reference, I provide the following to orient those following the story.

The apartment building in question has one way in — a locked metal door on the north side of the building. There’s no buzzer to allow entry, and the fire escape door is on the south side — it appears totally sit up — as in nobody would use it as an entry or exit. (Two days before the visit with Kematch another worker went by — twice — and couldn’t get in).

The windows are well above eye-level:




To get to the apartment in question, Zalevich and colleague Bill Leskiw would have climbed a short flight of stairs from the exterior door and open and pass through a fire door. Kematch’s apartment was immediately on the left to that door. Currently, it’s not numbered, but the others on the floor are.

(view from fire door]

The view into the one-bedroom apartment reveals the door opens directly onto a short hallway. To the immediate right is a bathroom, and the second door is a cupboard.

(View into apartment from doorway)


The bedroom where Kematch was said to have been locking her daughter up is eight steps from the door and in plain view of anyone standing in the hallway when the door is opened.

Kematch would have opened the door to the workers then likely shut it as they spoke. She would have opened it again when she went back inside to get the baby and then again to bring the baby out.

Kematch, not a small woman, would have obstructed their view of the hallway and bedroom door. She is not tall, however.

Again, I present this just to orient people with what those workers would had physically seen that day and the environment they were in. My only comment would be to say that the hallway where they talked with Kematch is narrow to the point of claustrophobia — especially with three people jammed into it. I would have felt uncomfortable trying to have a private conversation there, but that’s just me.

As well, it’s important to disregard the details in the photo – it’s been 8 years since they lived there and there naturally have been changes since — new paint, doorknobs etc. The white blob you see in the above picture was as a result of damage done to the bedroom door in the last few months and the new tenant patching it.


Phoenix Inquiry: Lies and the lying liar at the root of it all

(Samantha Kematch had the discretion to not murder her child.)
(Samantha Kematch)

“Don’t cry, I’m sorry to have deceived you so much, but that’s how life is.”  Nabokov

It could be that a key human resource problem Manitoba Child and Family Services faces is this: when you hire people professionally geared to see the best in others and what they might one day achieve, they might lack the capacity to see how horrific some of them could really be.

It’s the only reason jumping out to me as to just maybe why crisis response worker Christopher Zalevich elected to leave Phoenix Sinclair in the care of Samantha Kematch without even really trying to make an effort to see her in March 2005.

Zalevich makes an easy fall guy in Phoenix’s case, but to skewer him exclusively in light of all the systemic failings and questionable decisions we’ve seen so far is to kind of miss the point.

He had no formal child-welfare education or, for that matter, training. He has an ecology/family studies degree from the University of Manitoba. That was enough to get him in the CFS door and by 2002 he was working abuse unit cases, eventually winding up in crisis response where he remains to this day.

Zalevich’s only formal training in the much-discussed “provincial standards” came in 2007-08, years after he came to work at Winnipeg CFS in 2001.

Essentially, he says he learned on the job. Take that for what you will.

It’s easy to conclude Zalevich failed to put Phoenix’s welfare at the forefront.

He has to live with that, despite whatever justifications he had for believing Phoenix was safe when he recommended her mother’s file be closed.

[His whole dealing with Kematch raises the whole other issue, one that’s not overly complex but keeps cropping up: Who’s the client? The parent or the child? Hint: It’s supposed to be the child, but it’s not always seen that way.]

But despite putting Zalevich’s conduct and efforts on Phoenix’s file under a grim microscope today, there was a far more stark fact put briefly on the table that deserves more attention that it got.

It comes from a conclusion from a 2006 file review by Rhonda Warren.

Essentially, Warren found that over the years, since Phoenix was first given back to Kematch and then Steve Sinclair in August-September 2000, CFS workers actually saw her a total of four times.

And one of those was after she was apprehended into care from Sinclair in June 2003 and promptly given back to him by October despite the fact he had done nothing to prove he could care for her again.

The fact is, you can’t pin on Zalevich the real head-scratcher here: Kematch, in the eyes of the system, somehow magically transformed from horrible risk to children to fit and responsible parent in two years without her ever having to prove anything to CFS.

How this seemed to have happened was through a bizarre and downright confusing series of reports and case histories being watered down by each new crisis referral that came in, a lack of due diligence in delving deeper into said case histories, a chaotic system crushed by the weight of human need for help — and most importantly — CFS workers willing to simply accept what Kematch told them and not look any deeper. 

We see this over and over and over in this case.

Zalevich was just walking a path so many other of his colleagues did over the years: Following the trail of not seeing Samantha Kematch’s lies and failing seeing her hatred of the CFS system for what it was: a genuine risk factor.

Kematch learned by child number two, it seems, what telling the truth to CFS gets you — More CFS.

So her solution: Lie. and lie often. Then misdirect. Then give half-truths. There was one goal to it all:

Say whatever’s most convenient to get the agency out of your hair and away from your doorstep as fast as possible. 

It’s a combination of CFS gullibility and — it must be said — Kematch’s apparent skill as a crafty liar that helped put Phoenix on her horrific path.

Kematch loathed CFS.

It was so apparent. After all, she was a product of the system, having herself been a child in care. But the inquiry has heard that past CFS involvement didn’t really factor greatly into the moving target which is risk assessment.

Here’s a just a few examples of Kematch lying, misdirecting or hating on CFS and others:

  • She hid Phoenix’s pregnancy and that of Echo, born just a year after Phoenix. She also hid the pregnancy of her first child, a son taken from her at birth and ultimately made a permanent ward.

“Samantha sat the entire time in front of the TV – while this worker attempted to have a conversation with her — she would nodded or respond aggressively when asked a question.”

“Overall; it is evident to this worker that Samantha is annoyed and dislikes the involvement of WCFS – the family appears to doing well although Samantha does appear angry and annoyed with the agency involvement” — Feb 7 2001 file recording by Delores Chief Abigosis.

  • Lying in fall 2005 to a hospital social worker that Phoenix was alive and well despite the fact she had been long dead.

This lengthy little exchange in May-June 2004 (as summarized in 2006, again by Rhonda Warren) — this entire period was brought about by Kematch lying to a welfare worker about caring for Phoenix since before the prior Christmas and now seeking benefits for her.

The welfare worker, suspicious and concerned about conflicting reports on the risk Kematch may have been to Phoenix, called in a complaint to CFS worker Debbie De Gale. Here’s how that shook out:

Attempts were made to meet with Samantha prior to the date of actual contact and in fact the Intake Worker did make a home visit within the 48 hour Safety Assessment response time.

  • On May 13, 2004 workers attended Samantha’s residence. A man named Wes answered the door and said Samantha and Phoenix were at her Mother’s. 

  • On the same date a visit was made to the home of Samantha’s mother. Samantha was not there and said she and Phoenix were visiting friends. 

  • May 17, 2004 a letter was sent to Samantha saying the Intake Worker needed to meet with her. 

  • On June 2, 2004 the Intake Worker attended Samantha’s residence. Again there was no answer. 

  • On June 15, 2004 another letter was sent saying the Intake Worker needed to meet with Samantha. (Writer’s note: the letter said CFS couldn’t close its file on her until they met)

  • June 21, 2004 Samantha calls as she has received the letter. 

  • On June 28, 2004 Samantha calls to reschedule the next days meeting as she is moving. Samantha agreed to meet for a short while on the next day. 

  • June 29, 2004 Intake Worker attended Samantha’s address but could not gain entry to the block. 

  • July 9, 2004 Intake Worker gets Samantha’s new address from E&IA. 

  • July 13, 2004 Samantha makes contact with the Intake Worker who goes out to meet with her immediately. 

  • Samantha reports that she is doing fine with Phoenix. Workers see Phoenix who appears well cared for. Samantha also looks healthy and denies drug or alcohol use. There is no discussion of who Wes is or what his relationship is to Samantha. Samantha does state that her main support is her boyfriend who is a trucker and stays with her when he is in the city. 

  • Agency supports are offered to Samantha who declines. Community resource information is provided to her and the case is closed on Intake. 

  • During this interview with Samantha, she presented as stable and denied any substance abusing any substances. She did not exhibit any symptoms of drug abuse. Phoenix presented as healthy and well cared for. It was also noted that Samantha was involved in a relationship with Karl Wesley McKay who was employed as a truck driver….

  • WCFS assessed the risk to Phoenix as being low. Samantha declined services, but requested information community resources, which were provided by the Agency. The file was closed on July 15, 2004.

Another interesting clue from the mouth of her former common-law husband, Steve Sinclair in his Dec. 5 testimony:

Q: What was she like when you first got together with her?

A: She was quiet. She never talked about herself. Closed. I never asked …

Q: Now when you, when you met Samantha did you know that she had a baby?

A: Yes, I heard about that, yes …

Q: Did you know where the baby was?

A: Well. her — she didn’t really talk about it or her family never talked about it, so I guess I kind of figured her son might have been with CFS, so…

Q: You didn’t talk about it with her? …

Q: She didn’t talk to you about, about her background?

A: No.

The above is only really scratching the surface of Kematch’s spin.

Should Zalevich demanded to see Phoenix? Yes. Absolutely.

He ultimately admitted Phoenix’s welfare trumped Kematch’s privacy rights and her legislative right to the “least intrusive” dealings with CFS.

But the major thing separating his decisions made by so many others in the case is that Winnipeg CFS never got another chance to intervene.


Post note: I have been laying off the daily blogs of the inquiry due to 1] needing time to not think about it. 2] Recent days have been taxing.

But, more importantly, the inquiry is raising so many other issues and side questions that I’ve been working quietly on those as well in the background.

More to come.

Phoenix Inquiry: What CFS had on Karl (Carl?) ‘Wes’ (Wesley?) McKay and — when

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(Phoenix was murdered by Karl McKay and Samantha Kematch in 2005, months after CFS last had contact with her)

The last couple of days of testimony have delved into and exposed — to some decent degree — the fact CFS workers never searched out Karl Wesley McKay’s background or did a “prior contact check”  in the CFS database. Nor, it must be said — did CFS even ask for his full name when they discovered he was staying with Samantha Kematch and Phoenix in July 2004.

I’ve done stories here, and here on this vital issue. I don’t use the word vital lightly.

Here’s how it was put by former Winnipeg CFS intake supervisor Carolyn Parsons today of what happened when McKay’s name surfaced for the second time in 2004 on Dec. 1.

“I think if in this time we had been able to determine Mr. McKay’s history — that certainly would have changed everything and I think that’s something that every person who’s been involved with this situation wishes had happened.”

At that time, they entered the name they had in the CFSIS database and gave it a Jan. 1, 1980 date of birth — a typical practice when a person’s actual birthdate couldn’t be located.

Today, inquiry staff released an exhibit from the province as to what CFS workers would have found if they had been able to track his name in the system. It’s apparent there was confusion — and the issue exposes what was an apparent limitation of the computer system at the time.

Sometimes the first name McKay used was Carl, other times Wesley, sometimes Wesley Carl,  Wes and finally, Karl. Seems the only time in 2004 his real name appeared was on May 28, 2004 after he marched into a welfare office and tried to claim Phoenix on his budget.

Sadly, his name wouldn’t be conclusively linked to Kematch’s case in the CFS database until March 15, 2006 — five days after RCMP announced Phoenix’s death had been uncovered and McKay and Kematch arrested. I note with interest that RCMP at the time spelled his first name as “Carl.”

It was also around the very day RCMP laid first-degree murder charges against the despicable pair for the murder of Phoenix through abuse and confinement in a cold basement.

If CFS had dug into his background in 2004, they would have found him referenced in eight separate files dating back from March 1996 to fall 2000 when his partner’s two kids (one of them was his) were made permanent wards of CFS.

Here’s a just few lowlights of the disclosed files — and this is certainly not exhaustive:

  • April 1998: CFS informed McKay had (again) beaten up on his partner at the time, breaking her nose. Investigators felt neither he nor she had “any insight into the impact this was having on the two children and the potential risk to them … Probation services later advised of the severity of the assaults on ** by Carl McKay. These included him having taken the supporting leg off the bathroom sink and beating her with it.”
  • June 1998: One of the kids is found wearing only a diaper and a sweatshirt on the corner of William Avenue and Isabel Street in the company of a drunk male. “She was immediately apprehended,” the agency said.
  • Sept. 25 2008: “Wesley left a phone message stating (his partner) was an alcoholic and had problems. Wesley sounded as though he was intoxicated. He appeared to be very vindictive and left the message out of revenge.”
  • Early 1999: McKay fails to follow through in family violence programming and a “better fathering group” … “he failed to internalize his violent offending behaviour and had persisted in denying and/or minimizing the problem. It was apparent to probation services that Carl was only complying with the order minimally because he felt forced to do so.”
  • February 1999: His then partner heads to a shelter but is stays only a few days before going back to McKay. “It was her contention that the reasons she reconciled with him was that she had nowhere else to go.”
  • March 1999: “Report comes in through CFS that … (she) had been assaulted by Carl McKay.”
  • 1999: McKay is described as being “uncooperative” the agency.

Under a section called “identified problems,” a worker in September 2000 — the same month Kematch regained custody of Phoenix — wrote: “Carl Wesley McKay poses a threat to the children both directly and indirectly in terms of his propensity for violence,” and that he has little or “any insight into the impact … lifestyles have had on the two children. ”

Under ‘interventions,’ the worker says both McKay and his then-partner were “directed to participate in programming to address addictions issues, domestic violence, anger management, issues of victimization only to be met with failure.”

“My own contact with Mr. McKay has been non-existent in spite of several attempts. On several occasions I attended to his residence at (redacted) in order to serve him with court documents but without any success. In co-operation with probation services. I attended to the Law Courts building on the date of one of his court appearances for Breach of Probation. However he failed to appear in court.”

In June 2000, a worker wrote McKay was “identified by probation services as an extremely high offender re: domestic assault”

Like I said above, this was not exhaustive of what the files contain. But it spells out a little further what a risk McKay was.

McKay on the record in 2003, but not on CFS radar

That said — It hasn’t been mentioned yet that McKay’s name actually surfaced much earlier than 2004 — a year earlier in fact, and still no one appeared to ask who he was.

Note the date: This was right after Phoenix was taken into care a second time and Kematch suddenly surfaced after nearly two years expressing an interest in parenting her.

Most importantly: Note how McKay’s name is spelled . Odd, isn’t it? Odd because that’s the correct spelling.

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Now: here’s what the worker present — Laura Forrest had to say in her testimony about McKay’s appearance in court that day:

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“I asked her the name and she gave me the name and I believe a date of birth,” Laura Forrest said. It’s in my addendum, she said.

Here’s the relevant section of that addendum:

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“Worker learned that Samantha has been in a relationship with (redacted) DUB- October 12, 1974 – for two years. has met Phoenix and has some knowledge about the situation, but Samantha did not feel comfortable discussing all the issues in front of him. (redacted) companied Samantha to court.”

It’s Karl McKay’s name on the court transcript.

But his actual birthdate is March 28, 1962, not October ’74. Was it him? Or just another of Kematch’s lies to CFS?

Note how Forrest phrased this in her testimony: “I asked her his name and she gave me the name and I believe a date of birth.”

One thing’s apparent: It’s too bad questions weren’t posed directly to McKay himself.


Just for the heck of it, here’s a letter Probation Services wrote to CFS in 1999 about McKay.

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Redhead Inquest: CFS, damaged people and the concept of hope

(Jaylene Sanderson-Redhead)
(Jaylene Sanderson-Redhead)

Through the Phoenix Sinclair inquiry, among the things which have become well-established by now is that Child and Family Services — for all its perceived faults and obvious bungling of the little girl’s case for various reasons — is damned if it takes action, and damned if it doesn’t.

And the public backlash against the child-welfare system each time the death of a CFS-involved child is reported may go further than other reasons to explain why there’s so many kids in care today.

Wanting to avoid that backlash, the system appears today to be more inclined to act using the iron fist of apprehension over the velvet glove approach of family intervention and support as a first response.

But to apprehend a child into care — especially forever — is no small matter, either from a societal or legal standpoint.

And while acting in the safety, security and well-being of children is the highest principle of our CFS legislation, the concept of supporting and preserving families follows a close second.

I’ve written before about how those principles can be interpreted as contradictory, especially in light of the immense social problems some of our provincial communities face.

But if the concept of ‘hope’ didn’t exist in CFS — hope that social welfare systems and programming can heal people enough to make families (no matter the makeup) safe enough to leave kids in, the system would be not only more distrusted by many than it seems to be today but it would also be a black hole of despair and lost souls.

The moral question is where does the system draw the line? Where does the need to protect and apprehend trump reunification, support and preservation of families?

In his testimony this week at the inquest into the death of toddler Jaylene Redhead, psychologist Dr. Dell Ducharme allows us some insight into this.

Ducharme conducted an extensive assessment on Jaylene’s mother, Nicole Redhead, for Awasis CFS soon after she came to stay for the third time at a residential treatment centre in Winnipeg.

Redhead’s background as a child is beyond alarming, marred by violence, neglect and trauma unimaginable by virtually anyone.

Her dysfunction spilled into her adult years, winding up a crack addicted survivor of terrible domestic abuse at the hands of men described as “leeches” in testimony.

She had virtually no education or IQ to speak of really.

But — despite this, Redhead was trying to get clean and stable and “trying to heal,” Ducharme said.

Ducharme offered this response when asked what kind of future he saw for Nicole and Jaylene after surveying and contemplating her history:

“If I was a brand-new psychologist coming from a highly-rich white neighbourhood without any experience with first nation, I would probably look at this and be very afraid … you wouldn’t see any hope. You’d want to close the book right away — but that’s not the case based on my experience with family and also first nation — I’ve been going up to communities for over 15 years — her history, unfortunately, is not inconsistent with many of the other … young men and women that I see up north and do assessments on, where I do see individuals with backgrounds like Nicole being able to go on — based on presentation and support and healing — to go on and parent.

So what I’m seeing them within that larger context is somebody who was stable, was again coming back (to the treatment centre) … I assessed somebody that went and did it on the 15th time. (In Redhead) we see somebody who is coming back, wants to get better, is able to talk about her history of abuse and not fall apart – so she’s able to regulate, which is important — somebody who wants to heal and look after her children.”

In his conclusions, Ducharme only recommended a gradual and tightly supervised reunification of Jaylene and her mom for several reasons, including her inability to withstand stress, potential for relapse into addiction and other “red flags.” He described it as a “let’s see what we can do here” approach.

But hope for Redhead becoming a fit parent in late May 2008 was there, it’s clear. It was a start.

The problem — as it appears to have sadly been in Phoenix’s case as well — was oversight and follow-through.

It appears no one from Awasis CFS called Ducharme to discuss his findings, Redhead’s case switched hands and his report didn’t make its way into the hands of the treatment centre until he personally “broke protocol” and faxed it over to them five months later when Redhead’s case worker grew more and more concerned she hadn’t seen it.

By December 2008, CFS and Redhead entered into a supervisory order where it agreed to provide her with in-house supports as she began trying to care for Jaylene. She was smoking crack again by January 2009 and Jaylene was dead inside Redhead’s room at the treatment centre by late June of that year.

I trust Ducharme’s considerable experience that people – even severely damaged souls — can change. I believe that.

I also believe that it would be a lie to say our child-welfare system and the people brave enough to work in it haven’t done some good for many of its thousands and thousands of its clients over the decades.

But CFS, today, regardless of the fact both these horrific cases are years old, must find a way to demonstrate to the public it acts in a consistent and professional fashion in every case it touches in the province.

It must find a way to engage the general public in a realistic and understandable way to show the system is worthy of its trust.

And better yet: that we too can justify having hope.