WINNIPEG -- Three months before little Phoenix Sinclair was beaten to death, social workers had a final chance to intervene.
But a vague, second-hand tip that the girl was being abused was not treated as an emergency, the inquiry into Phoenix's death was told Monday.
"A child who may be abused, with no information on what the abuse is or that it actually even was abuse, is not considered an emergency by the after-hours unit," testified social worker Jacki Davidson.
The inquiry is examining how Manitoba child welfare failed to protect Phoenix, who spent much of her life in foster care or with family friends. The five-year-old girl was beaten to death in June 2005 by her mother Samantha Kematch and mother's boyfriend, Karl McKay, after Kematch had regained custody.
Kematch, McKay and Phoenix's father, Steve Sinclair, all had troubled, violent pasts that included substance abuse and Phoenix's child welfare file had been opened, closed and reopened many times during her short life.
In March 2005, two of Kematch's friends grew concerned that she was locking Phoenix in a bedroom and possibly abusing her. They reported their concerns to Child and Family Services anonymously, but said they weren't taken seriously. They asked another woman -- a foster parent -- to call as well. The identities of all three women cannot be revealed under a publication ban.
Davidson, a worker in the after-hours unit, took the call on the night of March 5, 2005, and recorded the allegations of abuse and a locked bedroom. But instead of going out to Kematch's home immediately, she referred the case for "consideration" to crisis response workers who worked during the day.
Davidson also said she did not designate the case as a formal abuse investigation, which would have prompted a detailed investigation by a special abuse unit, because the caller had not seen any abuse herself and could not provide any detail.
"Some people call in and say, 'I saw somebody at Safeway spanking their child.' They consider that physical abuse," Davidson said.
"Somebody would attend to the issue, but not as an emergency."
Derek Olson, one of the lawyers leading the inquiry, challenged Davidson's assessment. He pointed out Kematch and her daughter had a lengthy file of past troubles that were listed in the province's child welfare central database.
"But here you've got a history, a long history (with the family), doesn't that change how you view an allegation of abuse?"
The information from the caller was simply too vague to be treated as an emergency or to prompt a specialized abuse investigation, Davidson replied.
"I had no information that a child was being physically harmed, sexually harmed, emotionally harmed at that time."
An external review by Andrew Koster, a social work expert from Ontario, criticized the decision not to begin a formal abuse investigation.
"The determination not to treat this as an abuse case because it did not, in their opinion, meet the strict definition of the (law), was inappropriate," Koster wrote.
"This decision had dire consequences for Phoenix because it meant that the 14 required steps in an abuse investigation which would have potentially saved her life were not met."
Koster's review was completed in the fall of 2006 but is only being made public, section-by-section, at the inquiry as related evidence is presented.
Another social worker, Richard Buchkowski, testified Monday that he was assigned the case and tried to visit Kematch's apartment twice on March 7. He could not get into the building and was unable to contact Kematch.
Two days later, two other social workers went to Kematch's apartment and talked to her. She kept them out in the hallway and they left without seeing Phoenix. Her file was closed. Three months after that, Phoenix was beaten to death in the basement of Kematch and McKay's new home on the Fisher River Cree reserve north of Winnipeg.
The inquiry has already heard that social workers repeatedly missed warning signs that Phoenix was in danger.
The 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 McKay, the man 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.
Davidson had already dealt with the family in January 2004. She received a call from someone who said Kematch was drinking frequently and leaving Phoenix with a grandmother who smoked crack in the child's presence. As she did in 2005, Davidson did not treat the case as an emergency requiring an immediate visit, but referred it to crisis response workers for a followup in the ensuing days.
Another social worker visited the home of a family friend who was caring for Phoenix, decided all was well and shortly afterward closed the file.
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. McKay and Kematch were convicted of first-degree murder and sentenced to life in prison. Their trial was told they repeatedly hit, confined and abused Phoenix, sometimes shooting her with a BB gun and forcing her to eat her own vomit.
The two social workers who talked to Kematch in March 2005 and left without seeing Phoenix, Christopher Zalevich and Bill Leskiw, are to testify later this week.
