Lessons learned

Experience is a great teacher, but it is also a merciless one.

In May 2004, social worker Tracy Forbes caught Phoenix Sinclair's case from the Crisis Response Unit. Forbes was working in Intake and was asked to suss out the little girl's safety.

The agency had just learned Phoenix was living again with her mother, Samantha Kematch.  The concerned tip came from an Employment and Income Assistance worker who was asked to process a request to add Phoenix's child benefit to Kematch's budget.

Forbes testified today that at the time, the unit she was working in was cleaved in half by sick leave. Three social workers were off, leaving three others to do the work of six.

One of her previous statements, entered into evidence at the inquiry, compared her situation to running on a spinning wheel.

Forbes said she tried repeatedly to make contact with the little girl and her mother over the next few months at weekly and bi-weekly intervals.

There were concerns Phoenix was in a high-risk situation, but Forbes -- pressed for time -- had few weapons in her arsenal. All she could do was leave cards and send letters to Kematch, a woman with severe cognitive problems.

Forbes testified that when she was assigned Phoenix's file, she didn't try to contact other workers who had handled her case earlier that year.

Forbes said she also didn't try to contact or visit Phoenix's godparents, Rohan Stephenson or Kim Edwards, who might have shed more insight into the little girl's world and potential parental peril.

"In an ideal world," she said, she might have done those things and any number of other things, like spending more time with Samantha Kematch. Forbes only managed one brief visit with the mother.

Forbes said at one point, she came across a man identifying himself only as "Wes," who answered the door on one of Forbes' foiled attempts to visit Kematch.

Citing privacy concerns, Forbes did not identify herself as a CFS worker -- for all she knew, he was a plumber.

Kematch later told Forbes she was living with a trucker named "Wes." Forbes didn't blink. Kematch said "Wes" was her main support and a big presence in her life.  Forbes said she left it at that.

Asked why she didn't delve further into who this man was, or why she didn't run his name through agency records, Forbes told the inquiry it wasn't common practice.

Commission counsel Derek Olson then showed the inquiry exactly what would have come up had Forbes run Karl "Wes" McKay's name through CFSIS, the CFS database.

There were four files - hundreds of pages - detailing previous child apprehensions, violence, and substance abuse. There were also at least three arrests for assault.

Forbes didn't know any of this and downgraded the little girl's risk level to low. She closed the file.

One year later, Phoenix Sinclair was dead. McKay was the man who snuffed out the five-year-old's life.

It was an emotional moment for Forbes. She disclosed that the moment she heard of Phoenix's death, she knew she had been involved in the file.

She also testified that in later years, she would more diligently check the backgrounds of others who are involved in the care of children.

Most importantly, the child welfare system published new best practice guidelines requiring workers to run all adults in a child's orbit through CFSIS.

Its goal -- not stated but implied -- to weed out potential Karl McKays.

It's a terrible, but important, lesson to learn ... and one of many to come in the weeks ahead. It's too bad the cost of tuition was a little girl's life