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Why don't child-welfare agencies in Canada learn from the terrible deaths that happen under their noses?

In Newfoundland, government social workers left a baby boy in the custody of his mother even though she had been charged with the murder of her boyfriend. Shirley Turner went on to kill that 13-month-old boy, Zachary, and herself by jumping into the Atlantic Ocean.

In Manitoba, the authorities didn't notice that a five-year-old, Phoenix Sinclair, whose care they had overseen, went missing for nine months. Her mother and the mother's boyfriend have been charged with first-degree murder.

These deaths do not seem to have been aberrations. They are the natural result of deeply rooted failures in the child-protection system. Over and over, the parent, not the child, is treated as the primary client. No one is accountable for the child's well-being. But the most serious failure is the failure to learn from past mistakes.

Newfoundland produced a devastating report in 1989 into foster care and the generations-long abuses at the Mount Cashel boys home in St. John's. British Columbia's 1995 inquiry into the torture and suffocation of five-year-old Matthew Vaudreuil of Fort St. John was scorching. In Ontario, the 2001 inquest into the starvation death of five-week-old Jordan Heikamp of Toronto, whose mother was supervised by children's aid, showed that he was killed in plain sight of the authorities. And yet -- as B.C. Judge Thomas Gove wrote after his investigation into Matthew Vaudreuil's death -- nothing seems to change.

In Manitoba, reviews conducted after Phoenix was killed on the Fisher River Cree Nation reserve found that 20 children who were involved with protection authorities were killed between 2003 and 2006, mostly by their parents or guardians, and another 24 committed suicide. Six of the murdered children were under 4; in none of those six cases had protection workers bothered to assess the risk those children faced.

How on Earth could a child disappear after being involved with children's aid? Manitoba's government has not provided an answer yet. Neither the province's child advocate, Billie Schibler, nor its Ministry of Family Services sees fit to post on their websites the two public reviews of the child-protection system prompted by Phoenix's death. Ms. Schibler's office referred The Globe and Mail to the Winnipeg Free Press website. So much for accountability.

Why did Newfoundland's child-protection authorities leave an infant with a woman accused of murder? Believe it or not, it never occurred to them that he might be at risk from his mother, a physician charged in the United States who had fled to Canada and was free while fighting extradition. "The criminal matter, I guess, was left with the police and the Crown to deal with," a social worker said. "We weren't aware that there was any child-protection issues that were, you know, hidden in all of those things."

This is unfathomable. Child-welfare agencies have never had to wait for a criminal conviction before they acted. Justice moves slowly, children die all of a sudden. But as in the deaths of Matthew Vaudreuil and Jordan Heikamp, the authorities decided that Ms. Turner, who had come to them for support, was their main focus.

It is too early to say what happened in the deaths late last month of two girls,ages 1 and 3, in Barrie, Ont. Their mother, who was involved with children's aid, has been charged with murder in those deaths. Questions have been raised about her mental health before the deaths.

The latest probes -- Newfoundland's is more than 1,000 pages long -- give little reason to be optimistic about Canadian children in care.

What policy prescription can make up for the lack of accountability and basic sense in Newfoundland's government-run child-protection agency? Provincial law, even before Zachary's death, had changed so that no social worker could possibly miss the point: The child's best interests were "overriding and paramount" rather than simply paramount. The government-run agency missed the point anyway. And when Peter Markesteyn, a Winnipeg forensic pathologist who investigated Zachary's death, asked who in the agency was accountable for how that little boy and others do in care, the answer was: no one.

The overriding and paramount question now is when child-protection agencies will learn from all the tragedies they've been involved in.

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