A fatality inquiry report into the deaths of two young boys murdered by their father has concluded there were no flaws in the child-welfare system that allowed Jason Cardinal unsupervised visits with his sons.
The report into the deaths of Caleb and Gabriel Cardinal was made public by Alberta Justice on Thursday.
The inquiry judge made no recommendations.
The boys were six and three when they were drugged and strangled by their father during an unsupervised visit at his Edmonton townhouse on Dec. 19, 2010.
Alberta Provincial Court Judge Raymond Bodnarek acknowledged the benefit of hindsight that ultimately showed Cardinal's unsupervised access gave him the opportunity to carry out his plan to kill the boys.
But in his report, the judge ruled the child-welfare system made "reasonable judgement calls throughout their involvement with Caleb and Gabriel."
'Nothing in this story would make me happy'
He noted that while it was clear there were concerns about Cardinal's erratic behaviour and physical disciplining of the boys, "there was no indication Mr. Cardinal had the propensity to seriously hurt or kill his boys."
The day before the boys were found dead, Cardinal spoke to three people, including his mother and a psychologist. But the judge said even though Cardinal was about to carry out "unspeakable actions," he was able to fool everyone.
Cardinal himself was brought from prison to testify at the inquiry, in January 2016, along with child-welfare workers and others who had knowledge of the case.
The boys' mother, Andrea Badger, said she was frustrated with the report's findings.
"Nothing in this story would make me happy," she said, speaking from Caleb and Gabriel's grave close to her family's home at the Kehewin Cree Nation, northeast of Edmonton.
When the couple split, Badger was initially supported the idea of Cardinal taking care of the kids while she went to work at a camp outside Bonnyville in 2008.
But she said Cardinal, who has a history of mental illness, began to become unpredictable.
Her concerns escalated after she learned that Cardinal was spanking the two children, leading to them being apprehended in February 2010 by the child-intervention system.
"I was always worried about them when they were with him," she said.
After the apprehension, the boys were placed back into Badger's care. But Cardinal was allowed supervised visits a month later.
After he took parenting courses, the visits were changed to partially supervised and then unsupervised in the fall of that year.
At the time her sons died, Badger was fighting in court to try to regain custody.
Badger, 39, said she made it clear to the department of Children's Services that Cardinal was increasingly mean and aggressive and should not have been alone with the children at that point.
"That's what I told them in an email," she said. "I said he is going to hurt himself or somebody else."
In his report, the judge said Badger's warnings had to be balanced against the broader context of a custody battle in which both parents were arguing the other was an unfit parent.
Bodnarek wrote that none of the mental health professionals and caseworkers who worked with Jason Cardinal saw any signs the boys were in danger.
One worker told the inquiry that Cardinal had been doing well and there had been no problems during the subsequent three months of overnight visits with the children.
Now that she knows more, Badger believes Cardinal killed the children to hurt her.
"When my sons died they told me what was found at his place. There was a letter for me," she said.
She said the words Cardinal wrote at the end, "I win," still haunt her.
"I'm amazed at the amount of anger and evil in one person," she said.
The inquiry judge also made reference to Cardinal's "twisted logic," that his boys were better off dead than being raised by their mother.
Cardinal, 38, pleaded guilty to two counts of first-degree murder in 2012 and is now serving a life sentence with no chance of parole for 25 years.
The judge said the case highlights the devastating impact mental illness can have and the critical importance of timely access to services.
But he said terrible things can happen even with a properly functioning child-welfare system.
"This relates to the challenges of predicating human behaviour with absolute certainty."