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.

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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.

Screen Shot 2013-01-21 at 9.41.41 PM

Screen Shot 2013-01-21 at 9.41.56 PM

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.

Screen Shot 2013-01-22 at 9.25.34 AM Screen Shot 2013-01-22 at 9.25.52 AM

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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:

McGee-Exterior

 

McGee-Exterior-Door-Closer

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.

McGee-View-From-Firedoor
(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.

McGee-View-From-Doorway
(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.

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Phoenix Inquiry: Karl McKay’s digits and the perils of old technology

20120822-213238-g
(Karl McKay, 2006)

Exactly one month before a Winnipeg CFS worker went to probe an abuse complaint at Samantha Kematch’s home and left without physically seeing her daughter, another crisis-response worker along for the ride handled an unrelated call from her boyfriend, Karl Wesley (Wes) McKay.

And just two months before the Feb 9, 2005 intake unit referral Bill Leskiw handled, CFS had been scrambling to try and uncover information about McKay, but didn’t have his proper name or correct birthdate.

But a brief review of records tabled at the inquiry into Phoenix Sinclair’s death show that if internal files had been able to be cross-referenced by phone number at the time Leskiw dealt with McKay, CFS then had another chance to connect the dots and link the real Karl McKay to Samantha Kematch and Phoenix.

But it appears the limitations of the CFS computer system — CFSIS — in 2005 wouldn’t have allowed this. (CFSIS was created in 1993)

The inability of CFS to uncover who McKay actually was has been seen as a major turning point and failing of the child-welfare system in Phoenix’s case, with one supervisor saying uncovering the information likely would have “changed everything.”

Screen Shot 2013-01-16 at 6.28.25 PMHe and Kematch are serving life sentences for first-degree murder in connection to Phoenix’s June 14, 2005 death by horrific abuse. McKay was considered a “high risk” domestic violence offender who had a lengthy history with CFS and a major drinking problem.

Wednesday, the inquiry briefly tabled a document showing McKay called CFS and left a phone number of 783-7516.

That phone number is the same CFS had listed for Kematch when the agency became involved in her life after the birth of her fourth child on Nov. 30, 2004.

It’s also the number Kematch gave the welfare office and Manitoba Vital Statistics when applying for benefits days after the baby’s birth.

Given conduct of the case, worker Shelley Willox (then Wiebe) initially recommended — and her supervisor agreed — the file be transferred to a separate CFS unit to fully investigate Kematch, Phoenix and their living circumstances, also to get to the bottom of who “Wes McKay” was.

But the file was instead handed back to Willox for follow up, outside the expected practice within CFS, where CRU was only to hold files for up to 48 hours before transferring or closing them. She made calls trying to get information but found little at hand. The case was closed Dec. 7, 2004 citing a lack of child-protection concerns.

Fast forward to March 9, 2005, the day Leskiw and Christopher Zalevich met with Kematch at her home and left without seeing Phoenix despite the suspected abuse. Leskiw was only along for the ride as backup and said Wednesday he had no recall of the visit.

This became the last chance Winnipeg CFS would have to intervene in Phoenix’s life before Kematch and McKay moved to the Fisher River First Nation and murdered the little girl inside a home. Zalevich and his supervisor, Diva Faria, recommended the file be closed on the same day Zalevich visited the home and didn’t see Phoenix.

In the case history Zalevich was working off of, there’s no mention of McKay nor anything referring to the December 2004 intervention. It had been omitted after the worker who took the complaint cut-and-pasted the file history from other documents — a practice now forbidden in CFS crisis-response units.

Leskiw said he didn’t remember anything about the call that day or if Zalevich told him anything about why they were going to see Kematch.

He said there was no way for him to connect his February interaction with McKay with the call Zalevich was handling. “I have to focus on my own cases, my own files,” he said. No details of why McKay called CFS were discussed.

It was later disclosed in another record (April 18, 2005) relating to McKay’s ex that she had “adopted plans” to have one of McKay’s kids “stay with his birth dad, Karl McKay for the upcoming summer.” Leskiw was also referenced in that record as the “intake/service worker” at the time, but the record related to another CFS department.

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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.

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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

Screen Shot 2012-12-01 at 8.13.14 PM
(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.

Screen Shot 2012-12-18 at 9.09.27 PM

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

Screen Shot 2012-12-18 at 9.22.36 PM

Screen Shot 2012-12-18 at 9.22.49 PM Screen Shot 2012-12-18 at 9.23.09 PM

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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.

-30-

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

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Page 2:

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Phoenix inquiry: Proceed to memory

Screen Shot 2012-12-01 at 8.13.14 PM“A clear conscience is the sure sign of a bad memory.” —  Mark Twain

My memory is a blessing and a curse.

On one hand, I can recall nearly every article I’ve written for various media outlets in the past five years, including arcane details of events nobody but me would ever care about. I remember what it felt like to be places, to see things and experience them.

But on the other, I still struggle to remember other things, like the date of my parents’ wedding anniversary or buying coffee or milk for home when it runs out.

I’m confident saying, however, I remember my personal experiences with most, if not all people — both those familiar to me and interactions with strangers.

By virtue of my work I meet a lot of people. I’m not great with names, necessarily, but I remember their faces.

I also remember in unrelenting detail sitting with strangers in some of their most trying or difficult moments — and there’s been more than a handful of those moments in the last seven years.

Maybe I’m just special, but I doubt that. I’m no social worker, so my presence was likely not all that helpful. But I am human.

It’s been difficult for me to accept how former Winnipeg CFS supervisor Diana Verrier can’t remember one thing independently of CFS case files regarding her dealings with Phoenix Sinclair or her family between 2000 and 2004.

A day after Phoenix Sinclair was born, Verrier was there. She sat (or stood, we’ll never know) with Samantha Kematch and Steve Sinclair and gleaned the following information:

 Screen Shot 2012-12-11 at 8.00.23 PM Screen Shot 2012-12-11 at 8.00.37 PM Screen Shot 2012-12-11 at 8.00.52 PM Screen Shot 2012-12-11 at 8.01.01 PM
Even a cursory glance at the above reports shows Verrier was able to pull intimate details out of two perfect strangers (and Sinclair was noted for being private) prior to her and her partner putting a note on their hospital chart that their baby would be coming into CFS care.
She couldn’t, today, recall any of it — of them —  independently of her notes. She can’t remember baby Phoenix — whose travels through the CFS system from the day after she was born always seemed to  fail to rate much attention from anybody paid to look out for her.
Nor can Verrier remember signing off on two sepaearte CFS intake reports in early 2004, when Phoenix’s circumstances — do you know anyone named Phoenix? Would you forget them? — appeared to be murky and potentially dangerous and unstable. Maybe she didn’t read them, but that wouldn’t be good practice.
Third time’s the charm, right? By May 11, 2004, Verrier would be confronted again by some familiar names in the “history” section of a report that she signed off on:
————-

Both parents have been involved with child welfare agencies as permanent wards. Samantha became a ward of Cree Nation Child and Family Services in 1993 and Steven a ward of Winnipeg Child and Family Services in 1991. Samantha had one child, when she was seventeen years old who is a permanent ward in care of Cree Nation Child and Family Services. Steven and Samantha had two children together. Phoenix born on April 23, 2000 and apprehended at birth as neither parent was ready or prepared to parent their daughter. In September of 2000 Phoenix was returned to her parents. On April 29, 2001, they had another baby named who went to live with them and Phoenix. died of natural causes related to complications of pneumonia on July 15, 2001 while in the care of Steven shortly after Samantha and Steven separated. Phoenix remained with Steven and the file was closed in March 2002 because Steven did not want any further services from the agency. The file was re-opened on February 28, 2003 due to medical concerns about Phoenix having a foreign object in her nose and was infected. The file was subsequently transferred for ongoing service on June 27, 2003, after Phoenix was apprehended on June 23, 2003. Steven’s ability to parent his daughter had deteriorated to the point of him being under the influence most of the time and subjecting his daughter to inappropriate caregivers. Samantha was also known to be abusing substances and prostituting. Mr. Sinclair requested his child stay in care until he felt strong enough to care for her once again. Phoenix was returned to her father’s care on October 2, 2003. In Jan. /04, Samantha and a friend had a falling out and the friend contacted the Agency to report that Samantha drinks alcohol and smokes “rock” in front of Phoenix. Upon checking, it was determined that the Dad, Steven Sinclair was actually the primary caregiver since Phoenix was just a toddler. Samantha made allegations that Steven was drinking and neglecting Phoenix. Steven in turn made the same allegations against Samantha. It was then determined that phoenix was not living with either one of them as dad had privately placed her with family friends, Kim and Rohan Stevenson, while he got his life in order. As this appeared to be an acceptable arrangement, no further action was taken at the time, however, it was noted in the worker’s recording that Phoenix would be at risk if the situation changed and she was in he care of either parent. 

(The bolded sections represent things Verrier, as worker and later, supervisor, would have experienced first hand or read about the case in at least three different files she signed over the years.)
——————
Based on the foregoing, Debbie De Gale, who worked under Verrier, dug a little deeper:

(Source) called to report that Samantha has brought in a letter from her lawyer claiming that she has been caring for Phoenix since Nov. /03 and requested that she be provided financial assistance for phoenix. (Source) stated that the father, Steven Sinclair, has been receiving assistance for Phoenix however, he has been giving it to family friends, Kim and Rohan Stevenson.

was concerned about Phoenix being in her mother’s care, as it was understanding from the previous CFS worker that she would be at risk in either her mother or father’s care. Upon checking CFSIS, this worker was able to -confirm this to be true, provided updated demographic information on all concerned. This worker advised that I will look into this matter and get back to (source)

P/c to Kim and Rohan Stevenson. The person that answered the phone stating that I had the wrong phone number.

P/c to Steven. The phone number has been disconnected.

P/c to Samantha. She claimed that she has been caring for Phoenix since last November. This worker asked her how that came to be since, just in Feb. , phoenix had been privately placed with Kim and Rohan Stevenson. Samantha claimed that it was in fact her, who had placed Phoenix with the Stevenson and not Steven. This worker asked her how long Phoenix had been staying with the Stevensons. Samantha stated that Phoenix had been at the Stevenson’s for a month. This worker asked her why she would put Phoenix to stay with the Stevensons for that length of time, especially given the fact that she had only come back into her care recently (according to Samantha). Samantha then appeared to be at a loss for words, then suddenly she uttered a profanity and hung up the phone on this worker.

Despite this combined with the history and warning signs, Verrier ultimately saw the case as non-urgent, and assessed it as a 2-day follow up instead of one as De Gale had recommended. She described the history as laid out by De Gale above as being “typical” of many others which came across desks in the agency,

We can question that judgement (nobody from CFS saw Kematch until July, anyways), but the real question to me is: how is it remotely possible Verrier doesn’t remember these people at all?

Phoenix, Samantha, Steven: those three names linked together in multiple CFS case files over and over and over again over the years — some of them files she would have read and approved multiple times.

I can’t speak for anyone else, but to me, they — and others wrapped up in their sad, sad story —  have become unforgettable.

But it appears to many in CFS who handled the case, including Verrier — who no longer works in child-protection or in Manitoba — they — especially Phoenix — weren’t even worth a second thought.

-30-

Phoenix Inquiry: The curious case of the slimmed-down summary

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(Phoenix Sinclair)

Another illuminating moment today at the inquiry into how Phoenix Sinclair fell through the cracks of our provincial child-protection system.

It had to do with the information social workers rely on when assessing the urgency — some may describe that as ‘risk’ — when responding to a case; specifically, how soon Phoenix needed the system’s attention.

I’ve written before about social worker Laura Forrest being lauded in at least one internal review after Phoenix’s death (as well as by CFS employees on the witness stand) regarding her June 2003 case summary, which finally put together all available information about the case and the concerning backgrounds of her parents.

Forrest saw that, all things considered, her case was high risk and that CFS couldn’t go away from her life.

Her risk assessment would ultimately be deemed an “opinion” by subsequent workers and tossed aside to allow Steve Sinclair a fresh start with CFS and a new worker after Phoenix was taken from him in June 2003.

By the time Sinclair regained custody of her on Oct. 2, 2003, colleague and case worker Stan Williams’s closing summary of the case looked starkly different than Forrest’s.

I won’t reprint Forrest’s in its entirety, it’s pages long and extremely deep (it can be found here) Below, however, is the final, but still lengthy section in her ‘Statement of Risk.’

“Steven and Samantha have clearly indicated their mistrust and unwillingness to be involved with a child welfare agency however they have not demonstrated a capacity and commitment to ensure their child’s wellbeing enough for the agency not to be involved. Unfortunately. because of their past involvement as wards of a child welfare agency they arc not receptive to services from the agency and they deny or minimize any Issues presented in an effort to keep the agency away from them. They would do anything, or nothing, to keep the agency at bay. It is this worker’s opinion that it is this attitude and disregard for the agency that has probably resulted in this agency’s previous termination of services, and not a lack of child welfare issues, If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse lssue(s), and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and / or placement in agency care. Phoenix Is in agency care no(w) and it would probably not be in her best interests to be returned to either parent at this time or until they can show something to indicate that they can and will be more responsible and protective other.”

Now, for the sake of contrast, here’s Stan Williams’s final word on the case, under the “Unresolved Problems‘ section. It was authored around the time Phoenix was allowed by CFS to go back to dad unconditionally without having taken any programming for his alcohol problem.

“Mr. Sinclair requested his child stay in care until he felt strong enough to care for her again. He has had his time out and will parent Phoenix starting Oct. 2, 2003. He has done no programming and as such is prone to an unhealthy way of managing stresses in his life. He is aware of the need to arrange for appropriate alternative caregivers when he feels the need for a break or time out for respite.”

It goes without saying there’s a massive difference between the tone, content and, I submit — the intent of the two statements, prepared mere months apart by different social workers with apparently different mindsets.

But the net effect of this apparent discretionary revisionism was revealed today in relation to how another social worker, Lisa Conlin (and, her supervisor) started off their investigation into subsequent allegations Phoenix could be at risk in January 2004.

Conlin says she didn’t or can’t remember looking at past Kematch or Sinclair files the agency had on record when the file came to her on Jan. 20, 2004.

Did you look up either of the parents’ information on CFSIS (the internal computer system)?, commission counsel Sherri Walsh asked.

“Well, I believe I for sure would have looked at his (inaudible) that was open to me,” she said.

At Steve Sinclair’s?

“Steve Sinclair’s. That would be my typical practice,” she said.

And what would you have looked at? What information would you have looked at?

“The last closing summary,” Conlin replied.

So in this case, that’s the one at November 2003 (The Williams closing summary, referenced above.)? What about the one immediately before that — still in Mr. Sinclair’s file, from March 2002 — would you have looked at that one as well?

“I don’t specifically recall that one.”

You don’t recall looking at that one?

“No.”

Was it your practice, typically, just to look at the most recent file closing?

“Typically, because, what happens is the latest worker would have summarized already the previous closing summary — so you get a recent summary in the most recent closing. Just like when the intake initially comes to me from the Crisis Response Unit, there’s a summary … in there.” (To be fair, there was also a short ‘cut and pasted’ recounting of the family’s history and CFS involvement in that summary).

So if we look at the summary you would have reviewed … (Nov. 13, 2003, the Williams summary) under the heading ‘unresolved problems’ (Walsh reads the section, listed above, aloud to her)

“I don’t recall exactly when I looked at this,” she says. “It’s just something (as a matter of practice) I would have done,” said Conlin.

———

As you can clearly see, there’s a huge discrepancy in content and tone between the Forrest and Williams case summaries.

One (Forrest’s) darkly and deeply warns of the risk Phoenix was in and — by my reading — essentially urges the agency to stay involved in the little girl’s life.

The other, Williams’ laconic five-sentence-long summary essentially — to me — suggests almost the polar opposite – that the agency take a hands-off approach for the young dad who just needed a time out from parenting. (as if that wasn’t a warning sign in itself).

Problem is, when problems crept up again a few months later, Conlin, a busy social worker handling short-term child-protection intervention calls in the city’s most challenged area — likely only had so much time to delve into the file. Who knows. Maybe she just didn’t see the need to look further given the presenting child-welfare issues in the case she was to look into.

But it’s clear to me, at least, that it’s certainly more likely a social worker’s guard would have been raised significantly more if Forrest’s case summary had remained the one at the top of the pile.

-30-

Phoenix Inquiry: The truth about the complex truth

(Phoenix Sinclair)
(Phoenix Sinclair)

“This is an inquiry and an inquiry we must now proceed to do with all possible diligence.” Ted Hughes

To describe as ‘heroic’ any of the witnesses who have testified at the Phoenix Sinclair inquiry so far could appear as faulty as some of the decision-making employees of Child and Family Services made over the duration of the little girl’s involvement with the child-welfare system circa 2001-2004 — the period which we’ve been learning about so far.

But it’s my opinion if there’s any one of them deserving of a good measure of our respect today, it’s Heather Edinborough, for the simple reason that her candour has clearly put us closer to what we’re supposed to be after here: The truth of how a little child fell off the radar of Manitoba CFS and suffered horribly because of it.

Before I get to why I believe Edinborough should be lauded  (despite her admissions that several things in the Sinclair-Phoenix case weren’t done at all properly under her watch as a Winnipeg CFS Supervisor in 2003) there’s something I need to get off my chest about the inquiry and the role of the media.

And this is not a critique. Just an observation.

From this reporter’s perspective, the proceedings haven’t in any way been easy to cover.

The media, by and large, makes its hay by boiling things down into simple ‘opposition’ narratives reinforced by time-worn themes.

Good versus evil. Right battles wrong. David tackles Goliath.

Acknowledging this helps explain the overuse of the word ‘story/ies’ to describe the product readers and viewers consume and — in another sense — the newsgathering process itself.

“How’s that story coming, Turner?,” the editor barked.

Complexity is generally eschewed for the sake of the “story.”

But in the case of this inquiry, ‘boiling down’ or trying to make the information fit a story arc just won’t work.

I can’t see how it can happen and grow the public’s understanding of the machinations of our child-welfare system.

I am willing to accept my inability to see this could just speak to my skills as a journalist.

But if we’re going to get at the truth here and be able to communicate it meaningfully to shine light on Manitoba’s CFS system, it will only be done with the realization there is no easy 140-character narrative to do it through.

To unravel how Phoenix fell through the cracks and prevent other kids from the same fate, we’re going to have to wade far out into complexity and nuance; fully be OK with the undeniable fact it wasn’t ONE thing (say, incompetence) that led us to the sad place we’re at today.

Instead, it’s a whole host of circumstances at play inside an unwieldy and bureaucratic machine operating with a somewhat (it seems to me) contradictory mandate: protecting kids and trying to fix/reunite unhealthy families.

Couple the contradiction with the fact that how the mandate is fulfilled appears to involve huge amounts of discretion by various CFS actors, some performing the front line work (who don’t have standardized training) —  it’s easy to see how things could go wrong.

But one of the things I was reminded of by Heather Edinborough’s testimony on Friday is this: The vast majority of people doing CFS work aren’t bad people. They’re people who believe they can make a positive difference in people’s lives despite inordinate and complex challenges coming at them each day, every day.

In summer 2003, Edinborough, a Winnipeg CFS supervisor and social worker Stan Williams set about trying to do the right thing for Phoenix’s dad Steve Sinclair using the tools of the system they had to work with.

A natural virtue of that, as I see the underlying reasoning, is if they reached Sinclair — gave him a “fresh start” — got him on a positive path, then the system’s ultimate goal of protecting Phoenix in the long-term could be the happy consequence, along with their reunification.

Williams isn’t alive today to answer to the commission for his role in the case,  of what he and Sinclair discussed that so convinced him Phoenix could be returned after a “time out” without the young single dad doing the counselling Williams once clearly believed was vital. Or return her without a conditional agreement as had happened two years prior after the girl was first seized and returned.

It’s clear, to me, anyways, Williams understated concerns about Sinclair’s ability to parent when approaching Edinborough to sign off on his work and close the case.

We’ll never know why that is.

We do know Edinborough “winced” when reading his case closing summary at the time and says she continues to do so to this day.

She signed it anyways. Approved his work.

“The work wasn’t very good. It wasn’t enough. It wasn’t good enough,” she testified Friday.

Note how Edinborough didn’t say: “The work didn’t meet standards” or, “I don’t recall.”

The work Williams did was poor. Period. She signed off on it and I shouldn’t have. Period. No prevarication from her — just ownership.

So, then there’s one thing at play. The work was not good enough.

Then there’s the issue of the missing supervisory notes. A mystery.

And multiple issues about the lack of documentation in the social workers’ work.

And then the issue of how a child-protection case can go from one experienced worker seeing it as a “high-risk” situation, to another viewing it as low-risk within a matter of days when the only thing known that had changed was the child being seized.

The list of lacunae goes on and on.

Each problem carries with it a wealth of underpinning issues behind why.

These include, but aren’t limited to: workload/caseload demands, the fact social workers aren’t robots. Some of them weren’t up to the tasks. The fact new devolution policy was likely causing headaches and uncertainly in terms of who was going to be doing what and when and how and where. The fact the clients — truly the heart of the work — each presented different problems which needed to be considered and weighed.

RISK and SAFETY

Screen Shot 2012-12-01 at 8.13.14 PMBut Edinborough, to her credit and our benefit, shed a lot of light on what I see so far as the number one systemic issue which led to little Phoenix’s calamity.

(Setting aside for a second she had a despicable mother who kept house with a vile boyfriend).

It’s how CFS, again — in Phoenix’s lifetime — handled the concepts of “risk,” “safety” and assessment of potential future harm to a child.

(Having looked into the topic, one could have a public inquiry based just on this one general issue alone, I suspect).

Edinborough, like most other material witnesses, was asked to comment on the findings of internal and independent reviews conducted after Phoenix’s death was discovered.

One of them, a file review by Rhonda Warren, outlines succinctly the most confounding internal problem CFS  likely faced. Here’s the excerpt.

Risk Assessment

Statements of risk change from low to high without any change in circumstance. Statements of Safety are referred to as Statements of Risk. A family situation may be high risk even if on any given day the child is deemed to be safe. Unfortunately in this case `low safety assessments’ were deemed to be `low risk assessments’ which were not the case. This continuous error resulted in this case being closed numerous times without adequate intervention by the Agency. An Intake worker clearly articulated this problem in an assessment done in June 2003 (note: right before Edinborough took over the file). She states:

“It is this worker’s opinion that it is this attitude [resistance] and disregard for the Agency that has probably resulted in this Agency’s previous termination of services, and not lack of child welfare issues. If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the Agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse issues, and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and or placement in Agency care.” (This is from Laura Forrest’s file transfer on July 27, 2003 — Commission lawyer Sherri Walsh didn’t read this out directly to Edinborough as this section was discussed earlier in the day).

Unfortunately this statement was ultimately ignored once the case was transferred for ongoing service. Based on this case review it is apparent that Risk Assessment is not universally understood by Agency staff. (emphasis in original).

Here’s the verbatim response from Edinborough after Walsh read most of the above to her.

“I think that most of this section is absolutely accurate. I think — I hope the writer of this report knows a lot more about standards and safety, the difference between safety assessments and risk assessments than I certainly did at that time.

However, I think she’s hit the core of what the problem has been, and that’s because risk assessments in particular are based on people’s opinions which are formed by — as I said before — bringing our own values and experience, experience with that client that the risk of it changing every time a worker was assigned was there.

That risk — the risk of the risk changing that’s accurate — and it happened.

I think with the tool we discussed (more on this below), I think that’s less liable for that to happen … the substance of what she says here is absolutely accurate.

Walsh: You recall earlier, a very long time ago this morning, I asked you when an assessment was done as to Phoenix’s safety when she was returned to her father, if there was any concern given to long-term risk of harm at that point. 

Edinborough: “Right.” (She earlier testified she wouldn’t expect a social worker in 2003 to speak to the long-term prospect of harm a child may face given all the circumstances learned during a worker’s time with a case — see below).

And that’s what I meant — was were you considering at the moment she was being returned she was safe only? Or were you also considering what her future risk of harm or well-being would be?

Certainly her current safety, the potential of risk is certainly a consideration and factor into that. If we have indeed addressed some of the problems and believe the child is safe enough to return home, the belief is if those changes that were made persist, that the long-term safety of the child, or the long-term lack of risk to the child would continue to exist as well.

————-

Edinborough earlier testified on Friday: A file came to her office from the CFS intake unit with an assessment of risk on it. It was intake came up with an assessment of what the risk was.

When she got the file, her office would pay attention to that risk statement, but her expectation was risk would be assessed by the assigned social worker as he/she worked with the client. “Risk assessment continues to evolve based on the work that occurs.” She said at the time, in ’03, she wouldn’t have seen an intake “safety assessment” as being different from the concept of “risk assessment.” From intake, risk spoke to whatever the “risk might be. It varied.”

For her now (she recently retired from a high-up position at Michif CFS/Metis CFS authority), she says a safety assessment comes out of the (intake computer system) and “risk” is about the potential for future harm.

In 2003, she says the timeframe of the risk assessment looked at the period by which the file was open — “the goal always would be to reduce risk over the life of the file, over the life of the time the worker worked with the family.”

If a file arrived on her desk with high-medium risk, the goal was to reduce/eliminate risk. Harm could be abuse or neglect of a child, she agreed.

For the time your family service worker had the file, did you expect they would consider the child’s long-term well being, govern their actions based on that? 

Edinborough: “Depending perhaps on the age of the child, I wouldn’t expect a worker to say everything’s fine now and the infant was safe and then be able to predict – I don’t know how long term … They wouldn’t be able to predict how that child would do at school or what kind of teenager they’d be, so I’m not sure what you…

So then the actions taken on the file would not take into consideration those longer-term eventualities?

Edinborough: No, I wouldn’t expect a social worker to speak to that.

——————-

So then, given this realization, what’s changed to address this critical issue?

During the proceedings, a few witnesses have mentioned something called “structured decision making” or the “SDM tool.”

However, Instead of it being a concept, SDM is a computer-based case-management tool used to measure risk not only at the intake level, but also looks at likelihood of future harm for a child.

How it all works exactly will be discussed at length during the inquiries 2nd phase in the new year.

Some child-protection agencies in the U.S. have been using SDM now for many years.

From a report examining outcomes of SDM:

In 2002, North Carolina’s Department of Health and Human Services, Division of Social Services (the Division), implemented an SDM® case management system to assist child protection workers in making decisions at critical points during a child protective services (CPS) case …

The primary goal of the SDM case management system in CPS is to reduce the subsequent maltreatment of children in families in which an abuse or neglect incident has occurred. The underlying logic of the approach is that the most effective way to reduce child maltreatment is to accurately identify high risk families, prioritize them for agency service intervention, and deliver effective services appropriate to their needs.

The objective of a structured approach to case management is to increase the consistency, validity, utility, and equity of decisions at every agency level. Workers complete research- informed assessments at key decision points of a child protection case, and each assessment is designed to inform the relevant decision. This helps ensure that all workers consider the same information when making a decision and that assessment findings inform determinations of service delivery and prioritization. If assessment information is accessible, agency managers can use findings in aggregate to profile their clients, determine service needs and availability, and manage operations. These efforts are likely to increase the effectiveness of the child protection system.

General info on SDM is here. 

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Anyhow, we’ve come far afield.

I hope the above has made my point that if this inquiry is going to meet its mandate, we’re going to have to accept it’s a complex business, and complex to report on.

Simply playing the blame game won’t bring Phoenix justice.

In fact, I don’t know if that can ever happen.

No, there are no heroes here, but there may be some truth and understanding to be found if people like Edinborough continue to take the stand and be brave.

And to me, these days, truth and understanding appear to be a rare find indeed.

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“The better part of Valour, is Discretion”

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

A watershed moment came today in the Phoenix Sinclair Inquiry. One I’d been quietly waiting for since testimony really got underway a couple of weeks ago.

A Child and Family Services social worker uttered the single word that — to me, anyways — appears to underscore exactly how Phoenix wound up in the hideous predicament she did.

“Discretion.”

Its common definition is simple: “The freedom to decide what should be done in a situation.”

I’m beginning to see that discretion, at least as it relates to the evidence we’ve heard so far, figures in several ways in Phoenix’s tragedy on levels both systemic and personal.

And it can’t be forgotten, as a child, Phoenix had none of her own. In a sense, she was but a pawn in the act of everyone else exercising their own professional and personal autonomy, no matter their good intentions.

In terms of how it was broached today, former Winnipeg CFS supervisor Lorna Hanson described how social workers, at least in 2000-2001, had leeway in terms of how and when they reported their handwritten case notes into a case file.

(It maybe need not be said that when it comes to getting at the truth of what happened to Phoenix, notes — and the lack thereof — has become a major concern. More on this another time.)

“There’s some discretion of the social worker” on when notes go into the file, Hanson said. “Workers have to use some of their professional experience and discretion in those types of things.”

If we look closely at the evidence so far, we know there are far, far more examples of discretionary actions in this case. Maybe too many to count.

A small handful, in no particular order, would be (links as I can find them):

  • The decision by the hospital in April 2001 to allow Echo to return home with Kematch with little intervention despite knowing at least something about the family’s past issues.
  • The decision by CFS worker Delores Chief-Abigosis to not pursue the family’s case more aggressively in early 2001 after Kematch got snippy with her during the only home visit she did on the file where she notes seeing Phoenix. In fact much of her involvement — or lack thereof — could possibly be put down to discretion, as she has no recall of virtually anything and her notes about working on the case are scant.
  • The decision by Winnipeg CFS to allow Kematch and Sinclair to take Phoenix home with them prior to Kematch undergoing a psychological evaluation.
  • The decision by Winnipeg CFS to not pursue a full-blown parenting assessment conducted by a psychologist for Kematch, cited as being “costly.” the agency could have done this if they wanted.
  • Steve Sinclair’s (reported by CFS, anyways) decision to reject offers of voluntary agency services in the wake of Echo’s death in July 2001.
  • Kathy Epps and Lorna Hanson’s decision to close the Sinclair file in October 2001 despite not having physically seen Phoenix.
  • Kerri-Lynn Greeley’s decision on what to tell Dr. Gary Altman about the agency’s concerns prior to assessing (wait: ‘consulting’) with Kematch on Sept. 13, 2000
  • Altman’s decision to not meet with Kematch privately instead of with Sinclair and Phoenix in the room during said assessment.
  • Andrew Orobko’s decision to destroy his notes, material or immaterial as they may be.
  • Roberta Dick’s (and her supervisor’s) choice to mark a five-day response on a safety assessment in 2003, not the 48-hour assessment she now believes it should have been.
  • The decision by some internal investigators to not interview or consult some of the people involved when reviewing the case after Phoenix’s murder was discovered.
  • The decision by Karl McKay and Kematch to abuse, torture and murder an innocent little girl and callously bury her near a dump. No one can say they lacked the discretion to not do this.
  • Virtually every social worker’s case notations on the case are a matter of discretion. ‘Note this, not that.’ ‘This is important information to document.’ ‘That’s not.’

The list goes on and on in this case, and would also extend all the way up the ladder to government decision making.

People, professional people, paid to make decisions — in what sounds like awful circumstances — in cases involving children’s lives.

It goes without saying that without discretion, our world would decent into rule-book procedural chaos. Absolutely everything. I get that.

I’m generally okay with the idea that prosecutors and police officers, for example, should be allowed a measure of individual discretion in their different roles of trying to protect the public peace.

But CFS social workers aren’t cops. They aren’t Crowns.

They aren’t sworn or uniformed to protect and serve. Last I heard they labour under no oaths and aren’t even, by and large, registered with an oversight agency as registered nurses are.

That’s despite the fact they work in a clandestine system (words like ‘apprehension’ and ‘report,’ ‘crisis response’ and ‘investigation’ are pivotal CFS terms) which plays a major policing role to safeguard the well-being of our most vulnerable citizens.

Look, I don’t believe for a second that anyone would go through the effort and costs to become a social worker if they had any ill-intent.

But when Hanson testified today she believes that every social worker in the child-welfare system should receive mandated, standardized training, my jaw dropped.

‘That doesn’t already happen?,’ I thought.

It’s my belief — and I’m willing to be called out for being wrong — that when Commissioner Hughes issues his report on Phoenix’s case next fall, he’ll point to ‘discretion’ as a a major issue of why she got away from the system — from all of us — and wound up so horribly killed.

[Addendum: I just realized there was one additional example of ‘discretion’ I failed to mention: It’s incumbent on the government to ensure the social-welfare system is adequately resourced — especially when it comes to the protection of children. While I accept there’s been a number of efforts in recent years to address this, my understanding is more could still be done.]

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