Closing submissions continue Wednesday at an inquest into the case of a five-year-old boy who starved to death in his grandparents’ Toronto home.
Lawyers suggested Tuesday that Jeffrey Baldwin didn’t just slip through one crack, but through a whole institutional safety net.
The jury has already heard dozens of proposed recommendations aimed at various ministries and agencies during closing submissions.
The suggestions pointed to more than just one reason that Jeffrey died severely malnourished, unable to lift his own head while locked in a cold and putrid bedroom.
Rather, they indicate a constellation of institutional and personal failures.
The recommendations include using Jeffrey’s story as a case study for training children’s aid workers, and implementing better information sharing across agencies involved with child protection.
Though pneumonia was the cause of Jeffrey’s death, the jury has heard the underlying reason was chronic starvation.
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.