A coroner’s inquest jury hearing the case of a young boy whose grandparents starved him to death is being urged to adopt dozens of recommendations that could help prevent similar deaths in the future.
Various parties — from child welfare agencies to the provincial child and youth advocate — are giving closing submissions Tuesday at the inquest into the death of Jeffrey Baldwin.
Jeffrey was severely neglected in the care of his grandparents — who are now serving life sentences for second-degree murder — and when he died at age five he weighed about the same as he did as a baby.
As the inquest wraps up, coroner’s counsel Jill Witkin is presenting the jury with 74 suggested recommendations from all or most of the groups with standing.
The recommendations include using Jeffrey’s story as a case study for training children’s aid workers, implementing better information sharing across various agencies involved with child protection and starting a public awareness campaign about people’s duty to report suspected child abuse or neglect.
Both of Jeffrey’s grandparents had previous convictions for child abuse when they were granted custody of the boy and his siblings, but that wasn’t discovered in the Catholic Children’s Aid Society’s own files until after Jeffrey’s death.
The Catholic Children’s Aid Society has implemented many changes since Jeffrey’s death, including various iterations of record-keeping systems, but a manager told the inquest that gaps still remain.
Jeffrey’s parents were barely out of childhood themselves when they had four kids in quick succession, and nearly as swiftly they were taken away by children’s aid and handed over to the grandparents.
The inquest wasn’t held until 11 years after Jeffrey’s death because Bottineau only exhausted all of her appeals in 2012.
The coroner’s inquest is not looking to assign blame, but rather explore systemic issues surrounding Jeffrey’s death. The jury can make recommendations aimed at preventing such situations in the future.