The Manitoba government apologized for the child welfare system’s failure to protect Phoenix Sinclair, as the long-awaited inquiry report on the five-year-old girl’s death was released Friday.

The inquiry examined how the province's child welfare system failed the five-year-old girl before she was murdered by her mother and stepfather in 2005.

Inquiry blog

Catch up on what was said at the Phoenix Sinclair inquiry with our blog from the CBC's Katie Nicholson, who covered the hearings.

Led by commissioner Ted Hughes, the $14-million public inquiry — one of the biggest in Manitoba's history — sat for 91 days and heard testimony from 126 witnesses as it looked at how Child and Family Services (CFS) officials handled Phoenix's case during her brief life.

The report contains 62 recommendations for improving the child welfare system and is a call out to address “deeply rooted” issues, Hughes said in the executive summary.

“The responsibility to keep children safe cannot be borne by any single arm of government, or even by a single government,” Hughes stated. “It’s a responsibility that belongs to the entire community.”

The province said it will immediately act on the recommendations of the inquiry.

Family Services Minister Kerri Irvin-Ross also apologized on behalf of the province.

"The child welfare system failed Phoenix Sinclair. We deeply regret and are profoundly saddened by the loss of this child," she said.

Irvin-Ross said the goal is to take steps to correct the problems in the system, but it's unrealistic to think the recommendations will prevent another death.

She said however, it's still important to try.

"It is our goal," she said. "We need to make these changes for the families and for the children in Manitoba, that they know where they can go when they need support, that they're not afraid to reach out for support."

Irvin-Ross said the province has already taken action on 20 recommendations in the report. It is in the process of taking action on another 11.

As for the remaining 31, an “implementation team” is being created and will report back to Irvin-Ross by Sept. 30. The cost for the team is estimated at $350,000.

The Manitoba government also intends to:

  • Draft legislation to establish critical incident reporting similar to what is in place in the health-care system.
  • Make it mandatory for social workers to register with the Manitoba College of Social Workers and be subject to its professional standards and governance (similar to other colleges.)

National issue

Hughes said the child welfare system is on the right path, though it has more distance to cover.

“But the social and economic conditions that render children vulnerable to abuse and neglect are well beyond the scope of the child welfare system,” he wrote in the report.

 “In particular, the circumstances that bring aboriginal children to the child welfare system in such high numbers are deeply rooted in this country’s history and call out for special attention.

“This is a responsibility shared by us all.”

It is also a problem that extends beyond the boundaries of Manitoba, Hughes wrote.

"It is a serious national problem and it needs to be tackled at a national level. For that reason, I am recommending that the premier take this issue to the next meeting of the Council of the Federation and that he take the lead in urging his colleagues from the provinces and territories in a national dialogue to find solutions."

At risk from birth

"Phoenix Victoria Hope Sinclair was born a healthy baby with a lifetime of possibilities ahead of her. But she entered life in circumstances that were fraught with risk and it was clear from the start that her parents would need significant support if they were to make a safe and nurturing home for her," Hughes wrote.

He said Phoenix was left "defenceless against her mother's cruelty" and the "sadistic violence" of the woman's boyfriend.

He noted how child-welfare agencies were contacted 13 times with concerns about Phoenix during her short life — the last one coming three months before her death.

"Throughout, files were opened and closed, often without a social worker ever laying eyes on Phoenix," he wrote.

Report's conclusion

In commissioner Ted Hughes' words

"Phoenix was at risk from the day she was born. Her father loved her, but he lacked the skills to parent her and was struggling with addiction, unemployment, and his own troubled past. It will never be possible to prevent every tragic outcome for a child, but many of the interrelated factors that put Phoenix at risk are within our power to address and this is our collective responsibility.

"Protection of Manitoba children will take a concerted and collaborative effort from the child welfare system, other government departments, community-based organizations, and the general public.

"Despite all the steps that have already been taken in Manitoba, the number of children coming into the child welfare system, particularly aboriginal children, continues to rise.

"To truly honour Phoenix, we need to provide all of Manitoba’s children with a good start start in life, and offer to the most vulnerable an escape from the cycle of poverty and vulnerability that trapped Phoenix and her family.

"My hope is that the heart wrenching evidence I heard in Phase One of this inquiry, about Phoenix’s life and death, will serve as a catalyst to ensure that the recommendations that emerge from this report are wholeheartedly embraced and implemented. The protection of children is a shared value of the whole community. The public interest that this Inquiry has received encourages me in the belief that achievement of the better protection of all Manitoba’s children, and especially the most vulnerable, will be the true legacy of Phoenix Sinclair."

Death wasn't detected for 9 months

Phoenix spent most of her life in and out of foster care before she was returned to the care of her biological mother, Samantha Kematch, and her CFS file was closed in March 2005.

The inquiry was told that Kematch and her boyfriend, Karl McKay, took Phoenix to the Fisher River First Nation, about 150 kilometres north of Winnipeg, where the girl was beaten, shot at with a BB gun and neglected.

In June 2005, Phoenix was beaten and left to die on a basement floor.

Phoenix's death was not detected until nine months later, in March 2006, when one of her stepbrothers reported it to authorities.

Her body was wrapped in plastic and buried in a shallow grave near the reserve's landfill.

Kematch and McKay were convicted in 2008 of first-degree murder in Phoenix's death. They are currently serving life sentences.

Heavy workloads, mass confusion

The Hughes report recommends social workers have just 20 cases per worker, after the inquiry heard about struggles with heavy workloads.

CFS officials and social workers gave testimony about heavy workloads and a lack of necessary training or technology.

Some said a major restructuring of Manitoba's CFS system to make it more culturally appropriate and able to meet the needs of First Nations clients resulted in extensive confusion for staff and lost and misplaced files.

The inquiry also heard from those who were close to Phoenix, including her biological father, Steve Sinclair, and a friend of his, Kim Edwards, who cared for the child at one point.

"She is a child who has been a victim not only of a horrendous murder, but the victim of the incompetency of a system and a province," Edwards told the inquiry in December 2012.

Some who knew Phoenix or her family told the inquiry of their uneasiness in sharing information with authorities, as well as a fear of repercussions if they did so.

"What we need to look at is a big picture here and say, 'How can these things happen in this day and age, in a country as prosperous as ours, in a place where we put children first — or should be putting children first? How does this happen?'" Schibler said.

Six reports on the CFS system, containing a total of nearly 300 recommendations, have been released in the years since Phoenix died.

With files from The Canadian Press