A judge has found a Manitoba woman who smothered her young daughter was so poorly monitored by social workers and staff at a shelter that no one noticed she was doing crack cocaine in her room and beating the child.

An inquest report from provincial court Judge Lawrence Allen calls on the Manitoba government to reduce social worker caseloads and hire more specialists in fetal-alcohol spectrum disorder.

"Anyone who works in the medical, legal or child-welfare fields will tell you that the number of FASD-affected people has grown immensely in the last number of years," Allen wrote in the report released Friday.

"We as a society can and must do better to accommodate people affected by gestational alcohol consumption."

The inquest looked at the death of 21-month-old Jaylene Redhead in June 2009 at the hands of her mother. Nicole Redhead had suffered from fetal-alcohol syndrome and a traumatic childhood. She witnessed her own mother stab her father to death at a drinking party, the inquest was told.

Social workers had seized Redhead's previous two children and took Jaylene away after her birth in 2007. By the end of 2008, workers had set up a supervision plan to have Jaylene returned to her mother on the condition that the two live at the Native Women's Transition Centre in Winnipeg.

Allen questioned that decision by the Awasis child and family services agency.

"Many would question why, under the circumstances of two previous failed attempts at rehabilitation with previous children and with Jaylene born in drug withdrawal, Awasis agency would not have made permanency planning the only possible plan," Allen wrote.

"If there is any chance to preserve the parent-child bond no one would argue against the suggestion that in circumstances as fraught with peril as this one, all possible safeguards should have been employed."

Continued to do drugs

After a few months at the transition centre, Redhead was allowed out in the evenings and continued to do drugs.

She was not tested for drugs and staff believed she was doing fine.

"There does not appear to be any point to sending drug/alcohol addicted mothers to supposed 'safe houses' if these people are going to have free access to the community without making sure that their sobriety is being tested," says the report, which recommends that facilities such as the transition centre be subject to provincial child-welfare standards.

Social workers at Awasis believed Redhead was making progress in her parenting skills, although one worker filed a report in March 2009 that said Redhead did not have access to Jaylene when in fact the two had been living together at the centre for four months.

Social workers at Awasis were juggling roughly double the number of cases they should have been, the inquest was told, and were dealing with Redhead once a month, sometimes over the phone. That prompted the judge to call for more staff.

"In the case of agencies where workers are underpaid, over-worked and over-stressed, there exists a strong likelihood that the child- welfare services provided will be of a diminished quality."

Daughter smothered

Redhead killed her daughter by holding a hand over her mouth for up to two minutes, the inquest was told. She then put the toddler in a crib and left the room.

Redhead pleaded guilty to manslaughter. Her trial was told Jaylene had suffered more than 30 injuries in the days prior to her death, including bites and kicks.

The girl's death is one of several high-profile cases involving youngsters who fell through the cracks of Manitoba child welfare, including Phoenix Sinclair, whose death prompted a wide-ranging inquiry.

The NDP government has funded more front-line workers and has agreed to implement recommendations from the Phoenix Sinclair inquiry. It also passed a law several years ago to ensure social workers put the safety of children above any desire to reunite families.

That message was reinforced in Friday's report.

"Child welfare agencies have to continue to put the best interests of children first and be very careful that a desire to preserve parental rights does not come at the expense of the safety of a child."

The province said it accepts Lawrence's recommendations and will takes steps to "further strengthen the child-welfare system."

"Work is underway with the Manitoba Child and Family Service authorities to develop clearer standards that will help front-line workers protect children," Family Services Minister Kerri Irvin-Ross said in a statement.

"As well, stronger standards for community organizations that provide services to child-welfare clients are being drafted. These will include an annual audit."

Irvin-Ross also said the province will follow through to make sure child-welfare workers and agencies keep good notes and information into a database.

Statement from province

The province will take steps to further strengthen the child-welfare system as it accepts the recommendations of the inquest into the death of Jaylene Redhead, Family Services Minister Kerri Irvin-Ross said today.

"This was a tragic death and we want to thank Judge Lawrence Allen for his recommendations that will help improve the child-welfare system and protect our most vulnerable children," said Minister Irvin-Ross.  "This report reinforces the work that is already underway to strengthen those protections."

On June 29, 2009, Jaylene Redhead was killed by her mother, Nicole Redhead, while they were staying at the Native Women's Transition Centre in Winnipeg.  On April 20, 2011, Nicole Redhead pleaded guilty to manslaughter in the death of her daughter and received a 12-year sentence, which is currently being served.

The inquest report makes recommendations to the province, as well as to child-welfare authorities and agencies, on ways to improve the system and provide better protection to children in care, the minister said.

"Work is underway with the Manitoba Child and Family Service authorities to develop clearer standards that will help front-line workers protect children," Minister Irvin-Ross said.  "As well, stronger standards for community organizations that provide services to child-welfare clients are being drafted.  These will include an annual audit.

"Judge Allen reinforced the message that child-welfare workers and agencies must keep good notes and enter data into the information system to ensure no child falls through the cracks.  We will work with authorities and agencies to follow through on this recommendation."

The province will continue providing supports to authorities for fetal alcohol spectrum disorder specialists and require authorities and agencies to enter into agreements with community organizations that provide services to child-welfare clients.

The Province of Manitoba is committed to working with authorities, agencies and other service providers to support families while focusing on the collective priority of child safety, the minister said.