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Sagkeeng councillor Marilyn Courchene holds the report into the death of Tina Fontaine that was released by the Manitoba Advocate for Children and Youth on Tuesday.JOHN WOODS/The Canadian Press

Tina Fontaine reached out for help to social agencies multiple times in the weeks before she was found dead in Winnipeg’s Red River, but she was turned away and left at high risk for sexual exploitation, an investigation by the province’s children’s advocate has found.

The 115-page report from Manitoba’s Advocate for Children and Youth, Daphne Penrose, released on Tuesday, lays bare how systems meant to educate and protect vulnerable children failed the Anishinaabe teenager at every turn and continue to fail youth in the city. Twice on Aug. 1, 2014, the shy, soft-spoken 15-year-old visited city shelters asking for a place to sleep, but was told there were no beds.

The next day, she called Manitoba’s Child and Family Services (CFS). She wanted to go somewhere that "feels like it’s home.” But no homes with beds were available, so the social worker told her to go to a shelter where a bed had opened up. Tina was left to ride her bike there. Fifteen days later, her body was pulled from the Red River, tucked in the fetal position, wrapped in a duvet, wearing pink high-top runners, identifiable by the tattoo on her back: a pair of angel wings bearing her father’s name. She weighed 72 pounds.

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Daphne Penrose, left, the Manitoba Advocate for Children and Youth, embraces councillor Marilyn Courchene at the Sagkeeng Mino Pimatiziwin Family Treatment Centre prior to the release of a special report.JOHN WOODS/The Canadian Press

Ms. Penrose said Tina showed clear signs she was in danger of dying, but nothing was ever done. And, she said, nothing has improved in the city in the five years since, adding that she knows of 17 kids facing immediate danger.

“What’s at stake are the lives of children. What’s at stake is that children are going to die if we don’t make changes,” Ms. Penrose said as she released her report on the Sagkeeng First Nation, 115 kilometres northeast of Winnipeg, of which Tina was a member. “They are going to die in this way if we don’t get resources for them to access.”

Tina’s death shocked the city and the country. It brought renewed calls for an inquiry into the number of Indigenous women and girls who are murdered or go missing each year, and cast a harsh light on the responses of governments and law enforcement. Police were often slow to launch investigations, many of which were haphazardly carried out; and some politicians refused to make it a priority.

The story of Tina, as she is universally known in Winnipeg, broke the impasse. Her fragility and her youth made it impossible not to understand the urgency to hold a national inquiry, which the Liberal government launched in 2016. The final report from that inquiry is due later this spring.

No one has ever been convicted of a crime in connection with Tina’s disappearance and death. Last February, a jury acquitted Raymond Cormier of second-degree murder.

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Tears roll down the cheeks of Thelma Favel, Tina Fontaine's great-aunt and the woman who raised her, during a march in February, 2018, the day after the jury delivered a not-guilty verdict in the 2nd degree murder trial of Raymond Cormier.JOHN WOODS/CP

Ms. Penrose is calling on the province to provide safe and secure treatment facilities for kids in imminent danger, to create individually tailored response plans for missing children and to reduce barriers to access victim services.

She said the government needs to act quickly because children and youth still face the same risks and get the same responses.

“We have to also acknowledge the many other … children and youth who are falling through the cracks of society’s safety net, just like Tina.”

A spokesperson with the Manitoba government said: “There are important lessons to be learned from this tragedy,” adding that the province is “already taking action in areas recommended by the advocate.”

The picture that emerges over the 115-page report is of a jurisdictional mess, with Tina’s child welfare file being passed back and forth among the five separate agencies involved in her case during her life. From the notes made by social workers Ms. Penrose cites, none seemed fully aware of the extreme risks facing the 15-year-old in Winnipeg, even though she’d disclosed that she was using hard drugs, she was being sexually exploited and she had been picked up by police after she was heard screaming for help when an older man was dragging her down Selkirk Avenue by the arm.

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Grave site of Tina Fontaine on the Sagkeeng First Nation in Manitoba.LYLE STAFFORD/For The Globe and Mail

“Throughout her life, Tina needed an array of services from child and family, education, victim support, law enforcement, health, and mental health systems,” Ms. Penrose wrote. “At times, particularly in the final months of her life, some of these services were unavailable, not easily accessible, or ill-coordinated, which did not provide the supports and interventions she desperately needed.”

The report says Tina’s great-aunt, Thelma Favel, whom Tina called “grandma,” provided Tina and her sister a loving, stable home from the time the girls were 4 and 5. Her troubles began after the 2011 murder of their father, Eugene, a constant in their lives despite his struggles. The 41-year-old who called Tina his “little monkey” was beaten over several hours on the Sagkeeng First Nation, then tied up and left for dead. Tina seemed to fixate on a chilling detail: Her dad had been stomped so hard a Nike swoosh was left imprinted on his chest.

Her grief “grew and expanded until it began to manifest in difficulty at school, experimentation with drugs and alcohol, running away, increasing violence, and being sexually exploited by adult men who preyed on her,” the report said.

But she was never provided a single counselling session or cultural healing services after his death, “despite ongoing assessments and recommendations that this was a critical need in her life,” Ms. Penrose wrote.

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A photo of a fourteen-year-old Tina Fontaine at Thelma Favel's home on the Sagkeeng First Nation in Manitoba.LYLE STAFFORD/For The Globe and Mail

Tina didn’t seem to recognize the dangers around her. Two days before she was last seen, on Aug. 8, she approached a stranger outside a halfway house and asked for a cigarette. She had no money and nowhere to go, she told the man through tears. The man, James Sango, testified at Mr. Cormier’s trial that he shushed her loudly and warned her such talk made her prey to those who stalk the vulnerable.

This was also the way she encountered Mr. Cormier, who was out riding his bike one night, her friend Cody Mason testified. He brought them to the basement of a nearby home after she told him they had nowhere to stay.

“I could just picture her walking those streets, nobody helping her,” Ms. Favel said this week. “All the systems failed her.” She said she hoped the report’s recommendations might save another child like Tina.

With a report from The Canadian Press

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