The last Winnipeg social worker to check on Phoenix Sinclair, three months before the young girl was beaten to death, left the family's home without seeing Phoenix and without even stepping foot inside the apartment.
Christopher Zalevich, a crisis response worker, told the inquiry into Phoenix's death Tuesday he took the word of the girl's mother, Samantha Kematch, that all was well. Kematch and her boyfriend, Karl McKay would soon kill Phoenix after subjecting her to horrific abuse and neglect.
Read the latest entries from the CBC's Katie Nicholson, who is covering the Phoenix Sinclair inquiry:
"I believed at that time that (Phoenix) was safe. If I didn't believe that she was safe, then I wouldn't have made that recommendation to close the file," Zalevich testified.
The inquiry is examining how Manitoba child welfare failed to protect Phoenix, who spent most of her five years in foster care or with family friends before being handed back to Kematch, who had a long history of trouble.
Phoenix was frequently removed from her parents' care during her short life, only to be later given back to one or the other.
On March 5, 2005, the Winnipeg Child and Family Services agency received a tip that Phoenix was being abused by Kematch and locked inside a bedroom.
The tip came from a foster parent to other children who had received the information from someone else. Neither person can be identified under a publication ban.
Not allowed in apartment
On March 9, Zalevich and a colleague, Bill Leskiw, acted on the tip and visited Kematch's apartment building. She answered the door and kept them in the hallway, he recalled Tuesday.
"She indicated that she had someone visiting with her, so that's why she's not letting us into the apartment."
Zalevich didn't actually see whether there was a visitor. He can't recall all the details of the encounter, but said he probably asked to see Phoenix and was told she was elsewhere.
According to a report he filled out later that day, Zalevich asked Kematch whether she had abused Phoenix and she said she had simply yelled at the girl.
Kematch also confirmed that there was a lock on outside of the bedroom door and Zalevich said she shouldn't use it because it could be a hazard in the event of a fire.
Kematch then went back into the apartment because her youngest child, a baby, was crying. She brought the infant out into the hallway and Zalevich noted that the baby was clean, healthy and appeared well-cared for.
That was enough for Zalevich and Leskiw. They left without pressing the matter further and Zalevich recommended later that day that the file be closed. His supervisor agreed.
'Phoenix wasn't there'
Under questioning from Sherri Walsh, the lawyer leading the inquiry, Zalevich admitted he could have done more.
"So you accepted Ms. Kematch's explanation … and you didn't want to see Phoenix to determine whether Ms. Kematch's explanation was accurate?," Walsh asked.
"Ideally, I would want to see Phoenix," Zalevich replied.
"Was there anything preventing you from seeing Phoenix?"
"It was my understanding that Phoenix wasn't there."
"So you couldn't see her that day, at that visit. Was there any reason that you couldn't keep the file open until Phoenix had been seen?"
After a few more questions, Zalevich admitted: "No, there was nothing preventing my recommendation that that occur."
Walsh also pressed Zalevich on why he didn't insist on going in the apartment to see Phoenix's living conditions and check on the bedroom door lock. He was trying to be unintrusive, he replied.
Jeff Gindin, the lawyer for Phoenix's biological father, was even more blunt in his questioning.
"You should have demanded to come in and see what was going on," Gindin said.
"It wasn't agency standard," Zalevich replied.
"Did you really expect someone … to say to you, 'Yes, I really am abusing my child? Come right in and I'll tell you all about it?"' Gindin said later.
Missed warning signs
The inquiry has already heard that social workers repeatedly missed warning signs that Phoenix was in danger.
She was taken from Kematch and Steve Sinclair, her biological father, days after her birth because both parents had violent histories and were unprepared to care for her. Months later, Phoenix was given back to the couple.
Social workers were sometimes unaware of who was taking care of Phoenix — usually friends of the family or relatives for days or weeks at a time.
They also missed that Karl McKay, a boyfriend Kematch started living with in 2004, had a long history of domestic violence that including beating one former girlfriend with the leg off a bathroom sink.
Kematch and McKay were later convicted of first-degree murder in Phoenix's death and are serving life sentences.
Their trial was told they frequently confined and abused the girl, sometimes shooting her with a BB gun and forcing her to eat her own vomit. She died in June 2005 after a final assault.
Even after Phoenix's death, social workers believed she was still alive. Kematch and McKay continued to collect welfare benefits with the girl listed as a dependent.
Phoenix's death was only discovered in the spring of 2006 after a relative called police.