Protecting kids is not only the job of children's aid societies, but it is "every citizen's responsibility," a coroner's jury said Friday as it recommended sweeping changes to the child welfare system in Ontario.
Jeffrey Baldwin was a healthy baby when he and his siblings were placed in the care of their grandparents, but over the next few years the boy fell multiple times through society's safety nets and starved to death, locked in a cold, fetid bedroom.
When he died just shy of his sixth birthday his weight was that of a 10-month-old infant.
The jury in the coroner's inquest into Jeffrey's death issued a broad slate of 103 recommendations Friday, aimed at closing various gaps in the system so no other child meet's Jeffrey's fate.
The most glaring oversight in Jeffrey's case was the failure of the Catholic Children's Aid Society to check out Jeffrey's grandparents before giving them custody of the boy and his siblings.
Elva Bottineau and Norman Kidman had both previously been convicted of abusing children — Bottineau was convicted after her first baby died and was found to have multiple fractures, while Kidman was convicted after a beating sent two of Bottineau's other children to hospital.
But when Bottineau came forward to the CCAS and offered to care for her grandchildren, she seemed well-meaning and workers didn't look deeper, said Mary McConville, the executive director of the CCAS in Toronto.
"We should have known who Elva Bottineau and Norm Kidman were," she said after the jury's verdict.
"The entire child welfare system at that time had a collective blind spot around extended family."
A spokesman for the ministry said the initial rollout of the system to seven agencies should be done this summer, and after that it will be phased in at the remaining children's aid societies.
"CASs today use a variety of different information systems. The migration of historical data from these systems to CPIN is an expected challenge that we are addressing. We are taking the time to do this carefully and get it right," Neil Zacharjewicz said in an email.
Another recommendation said the ministry should also allow workers to access CPIN and the child abuse registry when they are assessing an alternate caregiver, such as a relative, and not just when investigating a child protection concern.
The jury also recommended that once CPIN is implemented, the ministry should study the feasibility of amalgamating all 46 individual children's aid societies into one co-ordinated agency.
Once a child has been placed in the care of a relative, that should not be the end of the road for children's aid societies, the jury recommended.
"The kinship service standards shall be amended to require an annual kinship service home visit for children five and under residing with alternate caregivers and following the closure of the case file," the jury recommended.
Jeffrey wasn't enrolled in school and teachers thought something might be wrong when his sister was ravenous at snack time and smelled of urine, but they didn't report it, the inquest heard. Jeffrey wasn't seen by a doctor since he was 18 months old, the inquest heard.
Bottineau's testimony at the inquest gave a glimpse into how Jeffrey might have ended up locked for long periods of time in his cold, urine-soaked, feces-stained, nearly barren room.
She said she was having a hard time with Jeffrey, who she described as having a "slow learning ability." She would lock him in his room to prevent him from drinking from the toilet, she said.
Dr. Stanley Zlotkin studied Jeffrey's autopsy photos and deemed them like nothing he had ever seen, despite having worked at the Hospital for Sick Children since 1980 and having done work in Africa.
"Jeffrey was literally skin and bones," he wrote in a report. "This child was likely chronically starved of food. There is no alternative hypothesis to explain the severe wasting and stunting."