As players in Manitoba’s Phoenix Sinclair Inquiry prepare to return to hearings later this month to present their final submissions to Commissioner Ted Hughes, a sweeping review of child-protection in the Australian state of Queensland has wrapped up with a full report on problems and solutions now in the hands of government.
From even just brief reading of the report [presented in full below], those involved in the PSI would do well to give it full, close reading.
It seems there’s an uncanny wealth of analogies to be made between their situation and the one Manitoba’s in.
Some quick excerpts:
1) “The enduring net effect of the implementation of recommendations from previous inquiries has been a systemic shift towards statutory child protection. This shift has been reinforced by a growing risk-averse culture in the department that promotes a forensic, rather than therapeutic, approach to child protection. Instead of investing in family support and other secondary services, departmental funds since 2000 have been directed to meeting the ever-increasing demand on the tertiary system.”
2) “According to most of the indicators currently used by policy makers to measure activities designed to safeguard vulnerable children, Queensland’s child protection system is under mounting stress. Over the last decade:
the number of child protection intakes has tripled (from 33,697 in 2001–02 to 114,503 in 2011–12)
the number of children in out-of-home care has more than doubled (from 3,257 in 2002 to 7,999 in 2012)
the rate of Aboriginal and Torres Strait Islander children in out-of-home care has tripled (from 12 children per 1,000 population in care in 2002 to 42 per 1,000 in care in 2012)
children in care are staying there for longer periods (with an increase in the proportion of children exiting care after one year or more from 38 per cent in 2001– 02 to 64 per cent in 2011–12).
In addition, while caseloads for child protection workers have fallen in recent years, they are still exceeding a manageable and sustainable level, and lifetime prospects for children leaving the care system continue to be poor.
Community concern about this unsatisfactory state of affairs led to the current government making an election commitment to review the child protection system with a view to finding the best possible outcomes for our most vulnerable children and their families.
3) “[T]he Commission is convinced by the argument (backed up by evidence) that wherever possible it is better for the child to stay at home — better for the child, better for the family and better for society as a whole. By supporting parents, we not only keep families together but we give parents an opportunity to contribute to their community.
Queensland’s situation is not unique. Similar problems can be found throughout Australia and across the western world. However, Queensland’s fiscal situation has made it imperative that it find out what is causing the system to malfunction, and to identify an affordable remedy.
I note of interest the title of the massive Queensland report: “Taking responsibility.”
I’ll be reading it in full with great interest. July 22 is the date the PSI is due to be back in session.
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.
“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.
From 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:
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]
People. From all walks of life. In one room. Talking about Child and Family Services in Manitoba.
Setting aside the fact Sunday’s meeting of minds at the River Heights Community Centre was sponsored by Manitoba Liberal Leader Dr. Jon Gerrard — he’s been one of the NDP government’s harshest critics on the CFS portfolio — I couldn’t help but be struck by the event just because it was happening at all.
Again: People. From all walks of life. In a room. Talking about CFS in Manitoba.
No intervening high-minded lawyers, no awful tragic child’s death anchoring it all and (virtually) no ranting and raving, or for that matter, much finger-pointing.
If there were one thing I could say I took away from the discussion (aside from the oddity that people rationally discussing a very live and vital issue in our society is somehow a marvel to behold), it would be this: People — the average Joe and Jane citizen — feel completely in the dark about CFS, how it works and what it does. But they care.
To many, it’s a gigantic government machine — “the feared child police” — which operates largely in secret and appears completely unaccountable for the decisions it makes — and that it make decisions about the lives of others which don’t appear to be working in a long-term sense. It bears remembering that many people touched by CFS aren’t the most sophisticated to start with.
Navigating complex legal and bureaucratic systems, for them, is unthinkable. And there’s not a whole host of advocacy routes to travel.
But let’s face facts: We have a terrible problem in Manitoba.
There’s an overwhelming number of kids in CFS care (many, if not most, aboriginal) and most they’re there not because of “abuse” — a nebulous and shifty term as set out in the CFS Act — but because of parental neglect.
No food in the fridge, mom and or dad or both drinking or splitting up, a shaky housing situation. These are just some of the instances of neglect which could move CFS to pull a child from his or her family and into care, and the parental issue triggering the apprehension may or may not get attended to.
It can’t be overstated: pulling a child from its family is no small thing. The aftershocks of that broken bond could last an entire lifetime. We have evidence in droves, including that unearthed by a years-long public inquiry, that the foster care and child-welfare systems is a feeder for youth jails, addictions and gang-involvement and, later, adult prisons.
[Two quick, but admittedly extreme examples: A 19-year-old man who lit a guy on fire in the north end and killed him? He had nearly 20 different foster placements in his short lifetime. Another man, who torched his Sherbrook Street apartment block around Christmas — he had 36 different CFS placements as a youth. The mass rejection a developing mind would feel from the constant shakeups is staggering.]
So, what do we do? Blaming the government won’t help. Blaming social workers won’t help.
But being given information and ideas to contemplate and question the status quo is a start.
And that’s what we should be doing.
Sunday’s meeting was an excellent example of this.
There were five speakers, and I’ll summarize a few of their views [as I understood them], briefly. This is not exhaustive.
First was Bernice Cyr, executive director of the Native Women’s Transition Centre and former CEO of Metis Child and Family Services.
While it’s pretty apparent what constitutes ‘safety,’ for kids — the concept of ‘risk’ (in the long-term sense) to a child is one that’s harder to get a grasp on. Because of new risk-assessment tools used by CFS (the Structured Decision Making computer risk evaluation, sarcastically dubbed the “cover your ass tool” by some), Cyr suggested that long-term risk can’t be addressed through apprehension of kids into care (because of the later “desperate outcomes” many of them encounter in other systems: health, criminal justice) and advocated for a greater use of what she described as “safety networks” for families in crisis.
Ultimately, Cyr believes child-welfare is a public concern to be addressed by the community/public agencies as a whole and not simply left to the ‘system’ to deal with in isolation.
Key point: in northern isolated communities, CFS is often the only resource available. The presence of health and other agencies can be skimpy or non-existent to meet people’s basic needs and protection centres for kids aren’t there, but CFS is, so a lot of burden is placed on the system.
Cyr also said the definition of ‘abuse’ in the CFS Act needs to be narrowed because it prevents social workers from developing more progressive practice habits. She also called for the expansion of the mandate of the Children’s Advocate office and the redirection of already-existing funding for family support interventions.
Next — and most interesting to me — was Lore Mirwaldt, a child protection and family support lawyer who practices up north.
In frank terms, she argued the CFS system as exists today is one that’s been thrust into isolation because of legislation and a hierarchical management/government system which operates in “crisis management” mode brought on by fear of making mistakes which become public controversies (Phoenix, Gage Guimond etc.).
“The name of the game is, ‘keep your cases off the front page of the Winnipeg Free Press,'” Mirwaldt said.
She took the 40 or so people gathered through the genesis of the so-called ‘devolution’ of the system as advanced by the AJI in 1991 and talked in depth about the problems which came out of the so-called “master agreement” the province signed with aboriginal leaders in 2000. While the principles of the agreement were to be lauded, Mirwaldt suggested the implementation was where it all went awry. As a result, the CFS system continues to wrestle with the problems that arose from the transfer of cases to aboriginal-run agencies years after the May 2005 ‘go-live’ of the new system.
“The problem is the government lost its nerve — they got scared,” she said. “They didn’t want to see any more dead children.”
In the north, some social workers handle astronomical caseloads of 70, whereas the recommended maximum caseloads are about a third of that.
As for the SDM tool, the standardized risk assessment questions (often called ‘probability of future harm’) that social workers must use in a case are often biased against northern kids, where ‘risk’ can be determined by the lack of a community store or other resources. Northern kids routinely come out of the computer-generated tool as “medium to high risk” and the solution for the worker is to apprehend, Mirwaldt said.
Overwhelmed by the soaring caseloads, workers on the Nisichawayasihk Cree Nation were encouraged by the director of their agency to “think outside the box.”
So they did, by moving to a philosophy Mirwald, tongue in cheek, called “apprehend the parent.” Through a band resolution passed by the NCN chief and council, parents who were creating unsafe atmospheres for their kids were removed from homes (remember, its the band who owns the property) and replaced by grandmothers and other appropriate caregivers to look after the kids. When parents protested, they were told to go work on their issues before they could return.
Most parents “eventually see the light,” she said, prompting the CFS agency to implement supervision orders to reunite the families with conditions.
The child stays in the home with relatives and is safe. The parent deals with the presenting problem or can’t return.
As a result of this “circle of care” strategy, Mirwald said Child Protection dockets in Thompson court have shrunk from 70 cases to as low as 22.
The problem is, she says, “bean counters” at CFS don’t know how to pay for the increase in in-home supports.
In the question/answer portion towards the end, Mirwaldt made an interesting point: Our priorities seem out of whack when a child can die in care and nobody gets fired, but if it was questionable spending a person is caught doing, they’d likely be turfed in a heartbeat.
She also said a worry is that declining caseloads will trigger a funding issue.
“We’re really afraid we’re going to lose our funding because our numbers are down,” she said.
Next to speak (and the last I’ll discuss in this post) was Bertha Traverse, a member of Little Saskatchewan First Nation and former long-term child welfare worker who specialized in working with at-risk youth.
She’s a staunch advocate of finding means to prevent apprehensions.
“Apprehension doesn’t work,” she said. “The bond that you have with family is broken the minute you’re taken out of your home — it’s irreparable,” she said.
Traverse spoke in scenes of realism — pointing out how on the 4th floor of the law courts building in Winnipeg, outside room 410 (where child-protection docket court is held), the vast majority of people there are aboriginal young mothers.
She also talked of how the government’s standards for social workers’ educations don’t always mean the workers are invested in the work.
“There is no damned degree that will ever teach you humanity,” she said.
Speaking of humanity, several in the audience offered insight into their personal predicaments and thoughts on the CFS system as a whole.
One of the most touching moments came from the undertaker who buried Gage Guimond.
He seemed to be questioning the entire philosophy of the social-welfare system and wondered what role “corruption” [his word] played in our society being unable to find solutions.
“The more you keep people poor, the more you keep them just running — the worse problems you have,” he said.
Another man spoke of the fear people have of CFS, and called for more advocacy resources for people to be able to navigate the system.
But it was one woman — an adoptee — who really gave me pause.
What the real problem is, she says, is how society has changed so much from when she was a child, when she would walk home from school and people would inquire of her if they hadn’t seen her sister or father that day.
We don’t look out for each other or even know each other any more, she said.
If we simply stuck together more, paid attention and cared, we’d be able to find solutions for the long-term benefit.
Maybe she’s right. But the cynic in me says we’ve come too far afield now to get back there.
I stand to be corrected, because ideally, I think she’s probably bang-on in her assessment.
The 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.
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.”
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.
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.
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.
O: That was an issue and that was something that workers were made aware of.
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 …
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.
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.
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.
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?
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.
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.