Tina Fontaine met social workers, police and health-care workers but no one kept her safe

Tina Fontaine was 15 when she came to Winnipeg in June 2014 to reconnect with her birth mother.

On Aug. 17, 2014, her 72-pound body, wrapped in a duvet cover and weighted down by rocks, was pulled from the Red River.

In the six weeks Tina was in Winnipeg, she came in contact with police officers, security officers, hospital staff and Child and Family Services.

What went wrong?

Tina's great-aunt Thelma Favel, who was Tina's primary caregiver, has wondered "What if?" from the time she found out about Tina's death.

"I just can't describe it how I am still feeling, knowing that if they did their jobs, my baby might still be here," Favel said in 2014 after Tina's body was found.

Outside court on Thursday, after Raymond Cormier was found not guilty of killing Tina, Indigenous leaders said society needs to do better.

"The systems, everything that was involved in Tina's life, failed her. We've all failed her. We as a nation need to do better for our young people," said Sheila North, grand chief of Manitoba Keewatinowi Okimakanak, which advocates for 30 First Nations.

The teen had already been through a lot before she went to Winnipeg, and her great-aunt had already had problems getting help from a system that's supposed to protect children at risk.

Father diagnosed with cancer

In 2003, when Tina was four, her father, Eugene Fontaine, was diagnosed with cancer.

That was the first time Child and Family Services became involved in Tina's life. Tina and her sister ended up in CFS care for six months before they were sent to live with Thelma and Joseph Favel, her great-aunt and great-uncle on Sagkeeng First Nation, Thelma said.

She thrived in the Favels' home. She loved school, baking cookies and playing with babies.

"Oh, she loved babies. She'd have all the babies on her bed and she would fall asleep there with them, and we asked her what do you want to do when you get older, and she said she wanted to work for CFS, the same that refused to help me," Thelma Favel told CBC News in February 2018.

• 'It helps me a lot to know we're not alone': Tina Fontaine's great-aunt on support during Cormier trial

On Oct. 31, 2011, it wasn't cancer that killed Tina's father. Eugene Fontaine was beaten to death. His body was found behind a garden shed in Sagkeeng. Nicholas Abraham and Jonathan Starr pleaded guilty to manslaughter in October 2014.

The family said Tina started to drift away as the 2014 trial for the men accused of killing her dadapproached.

On Nov. 1, 2013, Tina ran away from home and was reported missing to Powerview RCMP the following day. She was located safely on Nov. 4.

Tina was supposed to write a victim impact statement and struggled with it.

"She was just a kid. She didn't know how to deal with it; she didn't have nobody's support," Robyn Fontaine said about her niece.

Favel tried to get counselling for her great-niece from various Child and Family Services agencies, but was turned away.

Southeast CFS told her she was just outside their jurisdiction and said she should call Eastman CFS in Beausejour about an hour away, Favel said. Eastman couldn't help her either because she was a foster parent for Southeast CFS, she said.

Tina and her mom reunite

Tina wanted to reunite with her birth mother, Valentina Duck, who lived in Winnipeg.

Favel said Duck struggled with drug addiction and Favel feared she had associations with the sex trade, so she contacted Duck's CFS caseworkers to make sure it was safe for Tina to visit. It was, so Favel let Tina and her sister Sarah go to Winnipeg to see their mom.

At the end of the school year, Tina asked if she could visit her mom again and stay a week, Favel said in 2015.

"I didn't find out until later she'd lost custody of her kids and she was back on the streets," Favel said.

Favel gave Tina a long-distance card so she could call if things didn't work out and she wanted to come home before the week was over.

Tina and her sister Sarah went to Winnipeg on June 30, but Sarah changed her mind about staying and returned home right away.

Tina stayed and Favel never saw her again.

CFS failings

On July 10, Tina was reported missing to Powerview RCMP, and was described in a news release as "an at-risk youth."

Favel still hadn't heard from her by July 17 and she called Southeast CFS for help. Tina was found and placed in care.

Her first placement was the Capri Motel on Pembina Highway. A social worker said she went "AWOL" right away and was reported missing again.

After that, Favel said, information about Tina came infrequently.

She was placed at the Ndinawe Safe House on July 23 but lost her space on Aug. 1 after missing curfew a number of times. The safe house is a 16-bed shelter and provides basic necessities for children and youth in need.

CBC News asked Ndinawe's executive director if the temporary shelter made any changes to the way it deals with kids placed in their group home following Tina's death, but the calls were not returned.

Tina was reported missing four times in the three weeks between July 17 and Aug. 9, 2014, the last time she was seen alive. Favel said she wasn't notified about any of it.

"On [Aug.] 15th I called her worker to see, because I hadn't heard from her for a while. I just wanted to find out how Tina was doing," Favel said.

"She said she was sorry she forgot to tell me Tina had been AWOL for two weeks already."

CFS workers didn't even call her when the teen's body was found on Aug. 17, 2014, she said.

"I don't know what they're doing because I'm out here and they're in the city," she said in 2014. "They should be letting me know more things."

• Timeline: From Tina Fontaine's arrival in Winnipeg to Raymond Cormier's arrest

During the second-degree murder trial for Cormier, witnesses said Tina had visited a number of family members and friends in Winnipeg and even slept over on occasion.

Favel said no one called her to say they had seen Tina or ask if she knew the teen was in the city.

The court also heard from people who said Tina approached them strangers on the street and asked if she could crash on their couch.

During the trial, Favel learned things she never knew about Tina's time in Winnipeg.

"It's so painful and especially to see the people she was hanging around with. I used to cross the street just to avoid them," Favel said during the trial.

In the last two days before she vanished, Tina came into contact with police, was briefly admitted to hospital and was then returned to the custody of a CFS worker, Favel learned.

No one saved her.

Police failed to protect teen

On Aug. 8, the day before Tina disappeared, she came in contact with two Winnipeg police officers.

Constables Cornelis Brock Jansen and Craig Houle said they pulled over a truck being driven in a suspicious manner near Isabel Street and Logan Avenue. The man behind the wheel had a suspended driver's licence and was taken into custody.

• Teens in CFS care in Winnipeg hotels say they've seen prostitution, drugs
• Police, hospital, child welfare workers all saw Tina Fontaine in 12 hours before disappearance

Tina, who had been missing since July 30, was in the passenger seat. She told the officers her name was Tessa Twoheart, then gave another fake name before identifying herself.

Houle said he did not see an alert on the police computer indicating she was missing.

Tina told Jansen she lied about her identity because she thought she was in trouble and said she was staying at the Quest Inn, a hotel commonly used by CFS.

Jansen did not ask her age and said she looked mature. He let her go.

"Her name should have come up as a red flag, that she was a missing girl, and they just let her go," Favel said in 2014.

During the trial, Jansen said he was training Houle a new officer who had been on the job for a few weeks and asked him to search the computer. Houle didn't notice Tina was flagged as an at risk missing girl, and told Jansen she didn't have any warrants or orders.

Jansen testified that he should have done a better job checking.

The Winnipeg Police Service placed the two officers on administrative leave and conducted an internal investigation into their conduct. Both officers have since resigned.

Hospital also let Tina go

A few hours after the officers let Tina go, she was found passed out in a downtown parking lot behind a University of Winnipeg building, not far from where police had encountered her.

Paramedics were called and took the teen to hospital. Tina told Dr. Andrea Wilke Gilmore, an emergency room doctor at Health Sciences Centre who examined Tina, that she had taken alcohol, marijuana and "gabbys" the street name for an epilepsy drug called gabapentin that's sometimes used to get high.

Blood and urine tests taken at the hospital later showed Tina also had methamphetamine and cocaine in her system.

Cody Mason, Tina's boyfriend in Winnipeg who had gone home to St. Theresa Point First Nation by the time she disappeared, testified that Cormier gave the teen the gabbys in the days before her disappearance.

A social worker at the hospital notified Southeast CFS Tina was there. She stayed in the ER for a few hours then was released back into CFS care.

A spokesperson for the Winnipeg Regional Health Authority would not say whether there are policies or procedures set out for hospital staff to follow when treating vulnerable kids in CFS care.

The WRHA would not respond to questions about whether it reviewed the care Tina received, and what changes, if any, were made as a result.

CBC News also wanted to know what assessments are done on patients in CFS care to determine whether they are a risk to themselves and under what circumstances a hospital would keep them overnight or refer them to a secure facility.

The Winnipeg Regional Health Authority refused to provide ananswer to those questions, saying disclosure would impact the murder trial.

"Knowing that you are writing about this case shifts your request from generic to specific. Out of respect for the legal process, the WRHA will not offer information outside of that process," a spokesperson said in an email.

A spokesperson wouldn't make any further comment after the jury was sequestered, which meant there was no more danger of influencing their decision.

CFS bans hotel placements

Tina's death and the near death of another child in care spurred one major change kids in care are no longer placed in hotels.

The social worker who picked Tina up at the hospital testified that she got Tina a meal at McDonald's because she looked thin, then dropped her off at the Charterhouse Hotel in downtown Winnipeg, placing her in the custody of a respite worker from a private company hired by the province.

Tina didn't stay long before she went to meet friends at Portage Place mall. Workers testified they had no way to physically keep the teen in the hotel.

From 2007 to May 2012, the province housed an average of zero to 17 kids in hotels each month. In March 2014, that number tripled to 65.

CBC News talked to teens in care in 2014 who said they were introduced to drugs, alcohol and sexual exploitation while being housed in hotels.

The next year, the NDP provincial government said children in care would no longer be kept in Winnipeg hotels. It hired 80 new staff, created 90 more shelter beds and added 750 new foster homes to the system.

• Children in care to be taken out of Winnipeg hotels after serious attack on girl

A mediation program to solve conflicts between families and CFS agencies was also piloted.

A secure short-term six-bed crisis intervention program has been created to support girls age 12 to 17, a spokesperson for the current provincial government said in an email.

Partnerships have also been formed between the province and a number of community organizations to provide culturally appropriate counselling and supports for Indigenous youth.

The government also has changed its funding model for agencies so they can use preventative measures, rather than the existing practice of providing money to support children once they're in care.

The province is currently overhauling the child welfare system, working to place more kids with relatives who will be given supports to help care for them in their own communities.

Nearly four years have passed since Tina died and Favel is trying to heal. She was too distraught to speak after the verdict but earlier told CBC, "It's going to take a while, but I am trying to get myself to get at that point where I don't have to cry every time I talk about her, which is still very, very impossible to do.

"I'm always thinking about it, always. I just don't know what happened. I'd like to know, but I'll never get that chance to ask her."

With Tina's death unsolved, she's once again joined the long list of murdered and missing Indigenous women and girls. To many First Nations leaders, her case is symbolic of a broken system with no fix in sight.

Niigaan Sinclair, a native studies professor at the University of Manitoba and an Anishinaabe activist, voiced the concerns of many Indigenous people in Canada.

"What are we going to do now? How are we going to give our young people hope? And how are we going to stop this egregious violence from continuing to occur to our young people time and time and time again?"

How the system failed Tina Fontaine

7 years ago

Duration 2:35

Tina Fontaine was in Winnipeg for 6 weeks before her body was pulled from the Red River. In that time she visited family, friends, but also came in contact with police, paramedics, hospital staff and Child and Family Services. First Nations leaders say Tina was failed by the very system that was supposed to protect her.