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Coroner’s jury recommends a legal duty for everyone to report child abuse

Jeffrey Baldwin is shown in a Halloween costume in this undated handout photo released at the inquest into his death. THE CANADIAN PRESS/HO - Office of the Chief Coroner for Ontario

Jeffrey Baldwin is shown in a Halloween costume in this undated handout photo released at the inquest into his death. THE CANADIAN PRESS/HO - Office of the Chief Coroner for Ontario

Allison Jones, The Canadian Press

TORONTO - It is not only the responsibility of child-welfare workers to protect kids, rather the onus is on the entire community, a coroner’s jury signalled Friday with its broad slate of recommendations.

Five-year-old Jeffrey Baldwin slipped through the cracks of the system and died in 2002 severely malnourished and hidden away, the inquest into his death heard.

Jeffrey was a healthy baby when he and his siblings were placed in the care of their grandparents, but when he died just shy of his sixth birthday his weight was that of a 10-month-old infant.

Both of Jeffrey’s grandparents had previous convictions for child abuse, but those records weren’t discovered in the Catholic Children’s Aid Society’s own files until after his death.

Many of the jury’s recommendations focused on improved record keeping and information sharing, including urging the Ministry of Children and Youth Services to deliver on a long-promised province-wide system for children’s aid societies.

The government should amend legislation to allow child-welfare workers to look through records such as the child abuse registry in cases other than child protection ones — for example, when assessing a relative as a potential caregiver, the jury recommended.

The province should also explore the possibility of amalgamating Ontario’s 46 children’s aid societies, the jury recommended. There are four in Toronto alone, including for Catholic families, Jewish families and aboriginal families.

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 directed recommendations not only to changes that could be made by the Ministry of Children and Youth Services and the children’s aid agencies, but also several other provincial ministries, school boards, law enforcement agencies, the information and privacy commissioner of Ontario, doctors and fire chiefs.

During the inquest, which began in September and saw more than 300 exhibits, lawyers suggested Jeffrey didn’t just slip through one crack, but through a whole institutional safety net.

“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 — 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 — Elva Bottineau and Norman Kidman — were convicted of second-degree murder.

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 family’s caseworker testified that she had no concerns about Bottineau, who she thought was a reliable pillar of support when compared to Jeffrey’s often-volatile teenage parents, so she never conducted any records checks on her or Kidman.

Had those checks been done, workers would have found a disturbing history of child abuse.

After Bottineau’s first baby died of pneumonia in 1969 doctors found multiple untreated fractures and she was convicted of assault causing bodily harm.

Two different psychological evaluations cast major doubts on Bottineau’s ability to care for children.

Bottineau then had two more children, who were made Crown wards following a severe beating by Kidman that landed them in hospital. He was convicted of two counts of assault causing bodily harm.

Those two children later alleged horrific abuse and neglect, including being tied to their beds and locked in dog crates.

After those two kids were removed from the home, the Catholic Children’s Aid Society supervised Bottineau’s care of her and Kidman’s three daughters for a time.

There were records of abuse investigations in the following years, including allegations made about some children Bottineau cared for as a foster “day mom.”

Bottineau testified at the inquest and said she was having a hard time with Jeffrey, who she described as having a “slow learning ability.”

Her testimony 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.

Once she got permanent custody of him in family court Jeffrey was essentially hidden from the rest of the world. He was not enrolled in school because he was not toilet trained, Bottineau said.

Jeffrey had not been taken to a doctor since he was 18 months old, the inquest heard.

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.”

Many changes have already been made in the child welfare system since Jeffrey died in 2002, but all parties agree there is more to be done.

Standards for kinship care were overhauled in the wake of Jeffrey’s death and the CCAS maintains that in today’s regime Bottineau and Kidman’s histories would not have gone unnoticed.

The coroner’s inquest was not looking to assign blame, but rather explore systemic issues surrounding Jeffrey’s death.

The inquest was held more than a decade after Jeffrey’s death because Bottineau only exhausted all of her appeals last year.

© The Canadian Press, 2014