Inquiry into the Death of Phoenix Sinclair Reveals Continuing Failures



The Inquiry came in at a cost of $14 million, and it essentially found that multiple opportunities were “missed” to save Phoenix Sinclair. It was noted that “files were opened and closed, often without a social worker ever laying eyes on Phoenix.”

It was noted time and again that there was nothing unusual about the case. Nothing to distinguish it from among any of the others pouring in. “A number of witnesses testified that at the time, there was nothing extraordinary about this file,” wrote Hon. Ted Hughes.

Central to the inquiry was one question: “How could this have happened?” The report notes that in her opening statement on the first day of the hearings, Commission Counsel said that one of the questions this Inquiry needed to answer was:

How was it that Phoenix could become so invisible to a community that included social service agencies, schools, hospitals, family, and friends, as to literally disappear?

All told, the Inquiry tallied 13 opportunities to have potentially rescued Phoenix from her fate – a figure cited by some as the number of opportunities lost in the case of Elisa Izquierdo.1

A great deal was made of “Structured Decision Making,” a risk assessment device put out by the National Council on Crime and Delinquency Children’s Research Center.2

This tool will enable caseworkers to make better decisions. It has recently been adopted, and it needs three to five years of time be proven a success in the field, you see.

Regarding the utility of the SDM, Jay Rodgers, former CEO of Winnipeg CFS and current CEO of the General Authority, testified that, “One of the real values of using the SDM approach is that, because of the research that’s behind it, it has really crystallized the information that is needed to make particular decisions in the life of a case. And so it helps focus workers on the information that really matters to each decision.”

The Inquiry heard from Dr. Cindy Blackstock, executive director of the First Nations Child and Family Caring Society of Canada, and a recognized expert in the field of First Nations child welfare issues, who countered with a somewhat differing view:

She expressed concern about possible cultural bias in the SDM assessment tools. She cautioned about the wholesale application of tools that were developed for another population, without accounting for the different context of First Nations children.

Issues such as poverty are often conflated with neglect, she said. Most structured decision-making tools she has reviewed have codified structural issues such as poverty, and treated them as parental deficits. And answers to other questions will often disadvantage First Nations families, she said. For example, many of these tools ask about previous history of abuse: many First Nations families will tick that box because of residential school experiences, which are no fault of their own. It is important that those who use the tool are aware of its limitations and are given proper training, she said, because misapplication could result in the removal of a child from a parent.

Rogers in turn countered that assertion, as the report explains:

Rodgers testified that if there is cultural bias built into the SDM it will be corrected when the General Authority asks the Children’s Resource Center to do a validation study, which can be done only after three to five years’ experience with the tools in the jurisdiction. The study will help determine whether there is any cultural bias built into the SDM tools as they are being used in Manitoba. He said that in Minnesota a validation study suggested an anomaly with regard to Native Americans in that state and correction was made.


The Institute of Applied Research undertook an examination of the SDM for the Minnesota Department of Human Services in 2004, finding that while differences among items on the checklist “evened out” over minority subpopulations, there were two exceptions to the rule:

The exceptions to this rule were Southeast Asian families that received overall lower risk scores and American Indian families that received overall higher risk scores. These findings held when the analysis was limited to comparison of minority and majority populations in counties with substantial minority representation.

Regarding the instrument’s predictive validity overall, researchers concluded that it “was more accurate with Southeast Asian families and less accurate with American Indian families.”

The question of whether or not SDM is to blame for the “disproportionality rate” of Native American children in Minnesota’s child welfare system aside, the National Council of Juvenile and Family Court Judges issued Disproportionality Rates for Children of Color in Foster Care 2013 noting that while some states have managed to reduce their disproportionality rates, “some states have shown increases in their Native American disproportionality; Minnesota, for example, rose 48% since 2000, increasing from 8.1 to 12.”

As a general proposition, in a report published by the Centre of Excellence for Child Welfare, researchers concluded that their analysis of risk assessment added to the “mounting body of evidence that clinical judgment using a structured risk assessment tool is an unreliable foundation on which to base critical child protection decisions.”

Central to the problem of effectively rescuing children are two primary issues: cultural bias and poor decision-making. “The over-representation of Aboriginal children in Canadian child welfare systems is a serious national problem for which a solution must be found for the benefit of Aboriginal children, and all Canadians,” the report explains.

That stands as a stunning indictment of the system, and of its remarkable ability to sweep far-too-many of the wrong children into care, while overlooking the right ones. Time and again, this has been identified as among the central failures of the system.

Until such time as society abandons the cruel hoax that is child protection, and establishes a system that is truly supportive of families and children, such failures will continue to occur – and with alarming frequency.

1. See for example Joe Sexton, “Report Finds Many Errors in Handling Abuse Cases,” New York Times (October 9, 1996) (state investigation reveals that “roughly a dozen caseworkers, supervisors and managers had knowledge of the family’s involvement with the agency at one time or another, cites a litany of squandered chances to intervene”); Russ Buettner, “Staffers to Face Ouster, Censure,” Daily News, (January 2, 1997)(Elisa Izquierdo case described as one “in which the child welfare agency squandered repeated chances to intervene and save the child”).

2. According to the Center’s web site, “CRC has collaborated with child welfare agencies in 40 U.S. states, 3 Australian states and a territory, 4 Canadian provinces, Taiwan, and Bermuda, to construct actuarial risk assessment instruments, design and implement decision-support and data analysis systems, conduct workload studies, and evaluate agency service-delivery programs.” Structured Decision Making is a registered trademark of the Children’s Research Center.