Phoenix Inquiry: Watching the watchers, or, odd logic part II
Dan Berg had a lot to say today. At times, words flowed from the former Winnipeg CFS assistant program manager’s lips in a hard-to-get-a-bead-on torrent.
Many times, Berg answered whatever question was lobbed his way by splitting his response into several parts, making it hard to parse out exactly what he meant.
Berg, in 2003-2005 was the supervisor tasked with supervising workers in the Crisis Response Unit and Diva Faria, the unit’s go-to supervisor. To be fair, he also had a number of other key CFS programs to monitor under his watch, all housed in the same drab Portage Avenue building.
As was usual, the commission lawyers took their time building the groundwork of evidence under the witness, setting out for Commissioner Ted Hughes their history with child-welfare in Manitoba, the level of training they received from CFS and other salient issues, such as their knowledge of and reliance on provincial and CFS program standards.
Berg’s evidence today is important in the respect that the public got a glimpse of how the watchers — the CFS supervisors dealing directly with case workers — were watched by senior management like Berg in Phoenix’s day.
We learned through him that when he was hired into the role he wasn’t offered any specific training to do the job, one that he described as a “huge, huge responsibility, a big job,” Looking down into the well, we’ve already seen how the workers and supervisors Berg was overseeing, likewise had little specific training from CFS when taking on their roles. He denied under cross examination he wasn’t a good fit for the role.
Most, if not all CFS workers and supers we’ve heard from, were provided no training in the standards or risk assessment when they started — some not until years after Phoenix’s murder.
That’s not to say they weren’t capable employees — but it helps us set a baseline of expectations for what we’ve been hearing, maybe.
Through Berg, we learned a number of salient things, including that he, as one of three head honchos within the Intake unit in his time there, didn’t appear to find any issues with the way CFS workers handled Phoenix’s case.
Unlike many of those already called, Berg had the benefit of reading the files in full in September 2006 as well as reading the complete external/internal review reports done in the wake of Phoenix’s death.
“With the Phoenix Sinclair matter, were any performance concerns brought to you attention with respect to any of the workers?,” Commission lawyer Derek Olson asked him.
“Not at the time,” he said.
“Based on what you’ve reviewed, would you have expected anything — anything in those documents to raise performance issues with respect to the work done?
“There’s nothing that I’ve read that jumps out at me to cause me to believe that if I.. was a manager (evaluating) performance issues that I would discipline staff over? I’d say ‘no’ to that,” Berg said.
Fast forward to the afternoon session, when Olson and Berg’s exchanges appeared to take on a different tone. Nearly heated at some points.
The touch point came after a long series of questions about response times and how those were determined. Olson asked Berg if he was ever involved in the auditing of files. He said if serious client complaints came in he would get involved if an “independent” review was required, or, he suggested if it appeared clients involved in custody battles were using CFS as a method of comeuppance
In terms of formal auditing of workers’ files, Berg said a curious thing about the Crisis Response Unit, which has routinely been described as the place where the most serious and urgent matters got the most attention.
Files were audited “not so much at CRU, because CRU was such a short-term service,” Berg said. “Auditing probably didn’t make much sense there.”
That’s curious in the sense that again we’re seeing that the unit where the most key, sometimes life and death decisions, appeared to merit less, not greater oversight.
We saw this theme play out in the recent evidence of Berg’s CRU supervisor, Diva Faria, where she indirectly spelled out how oversight seemed to increase as files and families became more stable and moved on to “tier 2” intake or family service units.
It’s more odd CFS logic, no?
In any event, Berg went on to say there was no quality-assurance program in place at Intake when he was there. He says that there were some programs which came out of a connection to people in the quality assurance division of CFS.
“We didn’t have any other individual attached to us who was doing quality assurance,” he said.
Olson then moved directly on to Berg’s assessment of what’s been pointed to as a central failing of Phoenix’s case: The fact that two workers went to her mother’s home to investigate a non-specific claim Samantha Kematch was abusing her daughter and left without seeing the child. They went back to the office and Zalevich recommended the file be closed after not noting any child-protection concerns.
“That’s correct,” Berg said when asked if he knew that had happened. He then took time to review CRU worker Christopher Zalevich’s report in full. (36928).
I’m presenting the verbatim exchange of questions and answers on ‘the visit’ below.
But before going further, maybe you might do the same and look over the report yourself.
Derek Olson: I don’t think there’s any dispute or controversy over the fact they did not see Phoenix Sinclair at this time.
Dan Berg: That’s correct.
O: The allegation that they were there to investigate — I think (it was) referred to a non specified abuse allegation.
B: The original caller said she believed this child to be abused but couldn’t provide any kind of information about the physical address of where the family lived or identifying information about the kind of abuse allegations themselves.
O: I think she said abuse as well as locking Phoenix in the room.
B: That’s correct.
O: So based upon that, Mr. Zalevich and Mr. Leskiw are going out to determine if there’s anything to this, right? This abuse concern.
O: Generally speaking, it seems fairly basic that, in a case like that, a social worker would see the child who’s the subject of an abuse allegation. Is that fair?
B: General practice would be that you would see the child when you go out on a protection investigation.
O: And that’s not — I don’t want to use the term best practice — because it’s pretty basic, isn’t it?
B: Well it was in the Feb. 3, 2004 CRU minutes that CRU supervisor Faria outlined it very clearly when you’re conducting assessments, you should be conducting assessments by, wherever possible, seeing the child and seeing the family, and seeing the residents. And that was fairly accurately put as to what the expectation at the time was.
O: Especially when you’re dealing with possible abuse?
B: I think the fact that you’re out there on a protection investigation would suggest that those are things that you want to check on.
O: I know you don’t like the term ‘common sense,’ but it seems tone fairly common sense that if you get a report a child is being abused, you’d see the child.
B: You’d want to start with the parent and talk to the parent and you’d want to do all the steps that [Leskiw and Zalevich] did. You indicated yourself — sometimes assessment, if you believe it’s any validity to the report itself. And at the end of the day it might have been a more full and complete assessment had they seen the child.
O: My specific question was that it was pretty common sense that you’d want to see the child who’s the subject of an abuse allegation.
B: It would have been advisable to see the child.
O: [Barely pausing]I mean, here you have the mother who’s actually the one whose — she’s the accused abuser — that’s what the concern was.
B: I really didn’t see anything in the record that it’s the mother who is the abuser. I may have missed it, but I don’t think I saw that.
O: Maybe just helpful to pull it up on the screen – 36927 — under the presenting problem — it says that ‘this person told the source of referral that she suspects that Samantha Kematch was abusing her daughter, Phoenix, and that Samantha may be locking Phoenix in a bedroom.’ So that’s what I said before was correct, that it’s Samantha Kematch who was being accused of abusing her daughter. So in that case, what would you say about relying on Samantha Kematch in terms of determining whether or not there’s anything to this allegation?
B: Well I think you have to start with Samantha Kematch because [inaudible] abusing her daughter and I think they did start with that, they did talk to her directly about that, she denied that. She was open to them about yelling at her daughter, previous to that, recently previous to that. And they did talk about the lock on the door, and she confirmed to us that a bedroom she shared with her and her daughter — there was a lock on the door and she appeared to be open and responsive in regards to removing the lock, it being a fire hazard, a fire danger. In regards to seeing the child, it’s clear — they didn’t see the child.
O: They didn’t see the child, right? And not seeing the child in this case, when you look at it as a supervisor — was that appropriate?
B: It’s hard to say if it was appropriate or not. Best practice would have been that you would see the child. That would have been best practice.
O: But wouldn’t that have — just be basic social work practice? That you’re checking on an abuse allegation where the child — wouldn’t you see the child as part of it?
B: It would have been advisable to see the child.
O: So not seeing the child here, was that, was that appropriate? I mean, you’re a supervisor so you know whether or not …
B: Well, if you look under the standards in regards to protection investigation, the standards state that we’re to investigate a protection investigation within 10 days and see the person or the family — and, I, by our standards, they would have met the standard — they were out there before 10 days they did see [inaudible] they did see the family. They didn’t see the child.
O: [Again, barely a pause] Are you suggesting now that the standards are actually saying it wasn’t necessary to see this child, or a child under the subject of an abuse allegation with that?
O: [Cuts him off] I mean, I want your understanding of what’s required.
B: I guess we’re having to discern a bit between whether this is a protection investigation or an abuse investigation (Note: ‘abuse’ investigations had certain requirements before they could be officially called that at the time].
O: I’m not talking about investigation, just determining whether there’s anything to this allegation of abuse. They substantiated that the door was locked — there was a lock on the door, so that lends — I would think that would lend some credibility to the caller — going out with the information, the facts that you’re aware of, are you suggesting that the standards say you wouldn’t have to see the child?
B: I’m trying to help clarify a small but important point. That the standards are different if this situation is viewed as a protection investigation verse [sic] this is viewed as an abuse investigation. There are different requirements. There are different timelines and there are different expectations of how you follow up and who you need to see. And at the end of the day, it is, I believe, from reading all the information that they viewed this not as an abuse investigation, but that they viewed this as a protection investigation. And based on that determination, they’ve actually done what the requirement was under the standard at that time.
O: Were they at a point where they were able to decide whether this was an abuse investigation or a protection investigation?
B: That’s a question probably better answered by the worker and supervisor, but it would seem to me that when they did their involvement, wrote it up, they believed they did not have any protection concerns and as such, the worker made the recommendation to close off the case.
O: Right, that’s without seeing the child.
B: That’s without seeing the child.
O: So before we get to the recommendation to close and they’re closing it based on that they don’t think there are any concerns, but the goal is ultimately to determine whether or not the child is safe.
B: That’s one of the goals.
O: To do that, don’t you have to see the child?
B: I said it would have been a more complete assessment had they saw the child.
O: And when it comes to the standards, you’re not saying that there’s any question in your mind that whether or not the standards would require seeing the child.
B: I’m saying to you that if it’s a protection standard they met the requirement. If it’s an abuse standard that it would it be viewed on this being abuse, which I’m not saying that it was. The caller said it was abuse, it was very non-specific in outlining abuse related concerns. But the expectation in the standards — if it was viewed as abuse — is you would have had to see the child, you would have had to see the other children in the home, you would have had to see the parents or care providers in the home, you would would have to see the offending part if you thing the abuse had happened with the approval of police and there was a — and if it was viewed as abuse by our agency, there were 14 other requirements in the abuse program they would have to follow.
O: When these workers went out, they didn’t know if it was abuse or not. All they had was the allegation that was made, right? Right?
B: Well, they had the allegation that was made and then their involvement in their follow-up interview with the mom and their observations of her with the child [Kematch’s baby, not Phoenix.]
O: And the mom who is accused of abuse.
B: Yes. You pointed that out.
O: Just based on those facts, whether you characterize it as an abuse allegation or a protection concern, just based on those facts, isn’t the first thing you do — to find out whether or not there was anything to the concern, the abuse allegation?
B: That would have been invaluable and it would have been a more complete investigation.
O: [Long pause] The determination that there were no child-protection concerns is something that was made without seeing the child.
B: That’s correct.
O: Is that determination — is it even possible to make that determination without seeing the child? In a case like this?
B: Is it possible? I think we see an example here where that’s indeed that’s happened. That was a recommendation from the worker, and it was reviewed and signed off by a supervisor.
O: We know what happened — but you as a supervisor, a supervisor of a supervisor and you see this — would you be able to say the child is safe? There aren’t protection concerns?
B: You know, I have to answer that in kind of two ways. The first way would be: There were two staff that went out, one of the workers had 7 months experience in the abuse program. The other worker that went out with the first worker had 15 years of experience, most of that with the Crisis Response Unit — was a very experienced, seasoned CRU worker. And at the end of the day, I believe that the supervisor trusted the combination of the information from the two workers at the end of the day and made the decision to close the case off — due to ‘no protection concerns.’ I do not know what the workload related issues were going on at the time. I don’t know ..
O: [cuts him off] But, you’re not suggesting that workload should ever impact decisions — as to whether or not an allegation of abuse was investigated. And that would have a part in it.
B: Again: back to this being a protection investigation rather than an abuse investigation. In a protection investigation, there have been times, when it it really busy and you are having to make choices out there of what you can and can’t — what you can and can’t follow up on. That some of those difficult choices are made, there are times when children aren’t seen. It’s not our usual course of action, or what we believe that we want to do — it’s certainly not what we had in our minutes and reflected in our expectations.
O: The minutes you’re referring to, where its recorded that if there are child protection concerns, workers should get out if possible to see the child.
B: That’s correct. See the child and see the family and the residence.
O: Right. Those minutes were from Feb. 3, 2004.
O: That was an issue and that was something that workers were made aware of.
O: And that’s not specifically talking about abuse concerns, it’s just where there’s a child protection concern.
B: That’s correct.
O: That might be where someone leaves power tools out and the child is at risk, right? It’s pretty broad.
B: It’s pretty broad.
O: And abuse is a little more narrow than that. So … you have to look at the circumstances as the they present and make your determination based on that.
B: That’s correct.
O: And here we have the two workers at the door, who have the ability — when you say workload – they’re at the door at the time …
O: … They could have asked to see Phoenix at the time.
[Draws an objection from Berg’s lawyer, Kris Saxberg, as Zalevich testified asking to see Phoenix was something he would have done. This is true, Zalevich did testify he would have asked if Phoenix was there based on Kematch’s responses and his usual practice.]
Olson: We don’t know what happened at the door other than what’s recorded in the note right, Mr. Berg?
Berg: I just have the record that’s before me.
O: And as a supervisor to supervisors, that’s what you’d have, right?
B: Yes, sir.
O: If you look at it, knowing what you know today and that’s based on what’s in the note, would you have expected the worker to do more in terms of asking to see the child? Record whether it did?
B: That’s a difficult question. In [inaudible] workload. And at the end of the day, If I had a seasoned, experienced CRU worker who went out with one of my more junior staff who had 7 months experience in the abuse program, and they met with the mom. And they did discuss what they did, and at they end of the day that they were both of the opinion that they — that there wasn’t validity to the source of referral information when it came in, I would — I’d make exactly the same decision that the supervisor did.
O: As a supervisor, when you look at the document, the documenting here, the recording — there’s nothing to indicate what questions were asked of Ms. Kematch. Wouldn’t it be important to have a record of whether or not Ms. Kematch was co-operating with a request to see Phoenix, or whether she said Phoenix was at day care or at school — something setting that out clearly?
B: You’re asking me to respond as if I was the covering supervisor for that day.
B: And as the covering supervisor that day I might have had those questions. I might have had that — questions about what efforts they made to see the child. I do not know what was on their plate that day in terms of workload and other things that were happening and at the end of the day, they had options, if they wanted to. They could have taken this case, said, ‘we’ve gone out and done what we need to do — we’re going to send this back up to Tier 2 intake — that was an option. The second option that they had — as this was a very difficult time for all of us at Winnipeg Child and Family. So many family service units were closed, so we had developed a program at 835 Program … called it out ‘CRU diversion program.’ … they had two options that they could have, at the end of the day, chosen to have sent this case to. They could have said: ‘We want to have this child seen.’ those options were open to them. They believed that there were no protection concerns and so in their professional judgement, they made the decision to close the case. Wasn’t that they didn’t have options. It was that they believed there were no protection concerns and were satisfied with the information provided by the mom.
O: And you as a supervisor …
The Commissioner: Mr. Olson, I think we’re just going around in circles now.
[They move onto another area]
Funny, Mr. Hughes hasn’t made any of his findings public yet.
But he sure hit the nail on the head with his comment capping off that lengthy exchange.
Around in circles indeed.