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Introspection after kid death

A coroner's inquest into the death of a seven-year-old Toronto girl killed by her guardians says children in the child welfare system should have a say in how their case is handled.

Jurors in the Katelynn Sampson inquest say the child should always be at the centre of any investigation and should be consulted when crucial care decisions are made.

The five-member panel has delivered 173 recommendations, including many on the duty to report child abuse, the training of child protection workers and information sharing between agencies and law enforcement — which were key themes in the inquest.

Katelynn's battered body was found Aug. 3, 2008, after one of her guardians called 911 claiming the child had choked while eating.

Katelynn came to live with Donna Irving and Warren Johnson after her mother, who was addicted to crack, realized she could no longer care for the girl herself.

It was later discovered that a judge had granted the couple custody without knowing they had lengthy criminal records and previous involvement with child welfare agencies.

Irving and Johnson pleaded guilty in 2012 to second-degree murder and are serving life sentences.

The inquest, which began in November, aims to clarify the circumstances surrounding Katelynn's death and suggest ways to prevent similar tragedies in the future.

The sharing of information between Toronto's four overlapping child protection agencies has been a focus of the inquest.

The jury has heard that three agencies — including the Children's Aid Society of Toronto and Native Child and Family Services — were contacted about Katelynn or her guardians while she was living with them.

Responsibility for the file was given to Native Child and Family Services because of Irving's aboriginal heritage. The couple's file had been handled by Children's Aid before Native Child and Family Services was designated as a child welfare agency in 2004.

The agency's executive director admitted in his testimony that several opportunities to help Katelynn were missed but denied those mistakes led to her death.

Irving, who had lost two children to child protection services, was receiving voluntary support from the agency in caring for her other two children when Katelynn came to live in the home.

A caseworker noticed the girl a month later, but was told the couple was only babysitting, the inquest heard.

Later that summer, another caseworker opened a protection file after realizing Katelynn was living there. But it was quickly closed after Irving said Katelynn had gone back to live with her mother, which wasn't true.

No one at the agency spoke to Katelynn or her mother, Bernice Sampson. Shortly afterward, Irving severed all ties with Native Child and Family Services, the inquest heard.

Katelynn's school also called Children's Aid several times. Some of those calls were to clarify the custody arrangement between Sampson and Irving, but at least one was to report burns and bruises on her body.

Those calls were referred to Native Child and Family Services, though no investigation was launched.

A third agency, the Catholic Children's Aid Society, also received a call in early 2008 from a neighbour claiming that Irving was using crack and working as a prostitute, leaving Johnson— who also had substance abuse problems— to care for Katelynn and the couple's other children, according to testimony.

The Catholic agency sent the information to a caseworker at CAS who had previously dealt with Katelynn, but the caseworker doesn't recall receiving it.

In the spring of 2008, Irving herself called the Children's Aid after-hours line saying she wanted Katelynn removed from her home.

The matter was referred to Native Child and Family Services, but when a caseworker called her back more than two weeks later, Irving lied and said she was receiving help from the girl's school. Her file was once again closed at her request.

Katelynn was pulled from school in May 2008 under pretext of a death in Irving's family. A month later, when the school asked if Katelynn would return for the last days of the term, Irving said the girl was unable to come due to a broken leg.

Irving was granted full custody in early June, roughly two months before Katelynn died from septic shock as a result of her injuries. The inquest has heard she was beaten hard enough to rupture her liver.

Her mother's lawyer told the jury that despite the miscommunications, everyone around Katelynn had enough information to save her.

Katelynn was the victim of their "significantly flawed decision-making," Suzan Fraser said.

Among the changes that followed Katelynn's death was the creation of a uniform referral system shared by Toronto's four child welfare agencies, which also tracks whether the information has been received.

The province has also changed how courts deal with private custody arrangements to ensure judges consider police record checks and child welfare reports.



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