Coroner's jury: kids are everyone's concern
TORONTO - 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 â€” 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."
Standards surrounding so-called kinship care have changed since Jeffrey's death in 2002, but the jury's recommendations suggest there is much more to be done.
For one, the Ministry of Children and Youth Services should "fully deliver on its pledge" to implement a Child Protection Information Network within two years to all children's aid societies across the province. The system would allow societies to access each other's information and advocates say it has been promised for a long time.
"There was a call for a shared database, CPIN, after Jeffrey died and it's more than 10 years later...we hear that the ministry is perhaps six to seven years away from that," said Irwin Elman, the provincial advocate for children and youth.
"If we've decided that that's an instrumental change that can better protect our children, do it for goodness' sake."
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.
The minister for children and youth services said her ministry will review the recommendations and "take all necessary steps to further improve the child welfare system."
Premier Kathleen Wynne vowed that CPIN would be implemented.
"One of the things that is clear is that there has not been enough sharing of information among the CASs and so that is of paramount importance that we get that system in place," she said.
And 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.
The jury was clearly moved by Jeffrey's sad tale. One juror wiped away tears as coroner's counsel Jill Witkin read a statement on their behalf extending their sympathies to Jeffrey's siblings. Their lawyer says they are doing remarkably well with loving foster families.
They wrote at the end of their recommendations that they are "hopeful" a permanent memorial, such as a parkette, can be established for Jeffrey, to "provide the important ongoing public safety message that the protection of vulnerable children in Ontario is every citizen's responsibility."
There were many other opportunities, outside the child-welfare system, for Jeffrey to have been saved.
He 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.
Finally, not one of the six adults living in that home â€” Bottineau, Kidman, their two daughters and their partners â€” ever sought help for Jeffrey.
One daughter testified at the inquest that she "didn't pay that much attention" to Jeffrey's treatment and her partner told the inquest he noticed Jeffrey's slow decline and was "bugged" by it, but didn't want to "create friction" by reporting it.
The jury also recommended changes that could be made by several other provincial ministries, school boards, law enforcement agencies, the information and privacy commissioner of Ontario, doctors and fire chiefs.
"Child welfare doesn't just involve one child in child protection," said Freya Kristjanson, a lawyer who represented Jeffrey's siblings.
"Child welfare involves a whole community of protection. It involves schools, police and neighbours and professionals to report on abuse. It is changing the system and it is for all of us to think about child protection â€” helping the kids who live next door."
Professionals such as teachers, lawyers and doctors are legally obliged to report suspected child abuse, but there are no penalties for members of the public who fail to raise such concerns with the authorities. The jury wants to see that changed.
It also suggested a public awareness campaign about people's duty to report concerns about child abuse or neglect, and reminders to professionals about their legal duties.
The inquest jury issued a verdict of homicide, which in an inquest setting means another person contributed to his death. The finding was expected, as the boy's grandparents were convicted of second-degree murder.
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."