It has been more than a decade since five-year-old Jeffrey Baldwin starved to death at the hands of his grandparents, who were previously convicted of child abuse, in what has been called one of Canada's worst cases of child neglect.
A coroner's inquest into the Toronto boy's death is scheduled to start Monday and it will mark the first real, public examination of the factors involved in the boy's horrific life and death, said Ontario's advocate for children and youth.
Some will say, "What's the point? That was 11 years ago," said Irwin Elman.
"The way of thinking happens that says, 'Well, we've done a lot of changes since 11 years ago so you can look away.' I think the important point for the public to understand is this is a chance to learn how today to better protect our children."
The child welfare system in Ontario has undergone many changes since the Catholic Children's Aid Society (CCAS) in Toronto placed Jeffrey and his siblings in the care of Elva Bottineau and Norman Kidman.
Major changes include increased checks of criminal records and family histories, as well as subjecting relatives who become caregivers to the same rigorous standards as foster parents and adoptive parents.
Impact of death
The Ministry of Child and Youth Services is also rolling out a Child Protection Information Network, slated to be fully in place next year. It is intended to help track cases across the province's 46 children's aid societies.
In the years after Jeffrey's death the CCAS learned a "tremendous amount" from the reviews and reports that have already been done, said Mary McConville, the society's executive director.
'Jeffrey's death is an enormous tragedy — a loss that is deeply felt and one that still reverberates throughout the society to this day.' —Mary McConville, Catholic Children's Aid Society
"Jeffrey's death is an enormous tragedy — a loss that is deeply felt and one that still reverberates throughout the society to this day," she said in a statement.
"The (CCAS) profoundly regrets Jeffrey's death at the hands of his grandparents, as well as the harm done to his surviving siblings."
Bottineau and Kidman were convicted of second-degree murder in 2006 and sentenced to life in prison with no parole for 22 and 20 years, respectively. They tried unsuccessfully to appeal their convictions up to the Supreme Court of Canada, and with the high court refusing last year to hear their appeals, the coroner's inquest could move forward.
The child welfare system has indeed changed since Jeffrey's 2002 death, Elman said, but he hopes it can shed light on what hasn't changed.
"The (Child Protection Information Network) isn't here yet. It's 11 years and it's not here yet," he said.
"So what else isn't here yet but may be being promised? This is a time for the public to say, 'Yep, we understand. We've made an obligation to children in this province, we as a province have, and we want to examine how we're doing."
For one, some say the system still lacks proper oversight.
Ombudsman without power
Ontario is the only province in which the ombudsman has no power to investigate complaints against children's aid societies.
Between various regions as well as Catholic, Jewish and First Nations children's aid societies in Ontario almost 48,000 families were served last year.
He can't investigate them, but Ontario's ombudsman has still received more than 3,500 complaints since 2005. Andre Marin said it's time he oversaw the child protection system.
"It's shocking, quite frankly," Marin said. "I can take complaints by inmates about how they're treated but I cannot take complaints from families about how they're treated by the CAS."
There are a lot of systemic issues in Jeffrey's case, Elman said. It's not just about protecting children from dying, but also protecting them from abuse and neglect, he said.
"When a child dies it's the tip of the iceberg because there are other children, you would think, who are in difficult circumstances who we need to make sure are doing better."
Jeffrey weighed only 21 pounds and was covered in sores when he died, weeks shy of his sixth birthday, from complications due to chronic starvation. Jeffrey and his sister were confined to an unheated bedroom for as long as 14 hours a day, breathing in the stench of their own urine and feces.
Although the siblings lived in squalor, the rest of the house was normal, including the living quarters of other children in the home.
Deaths while in care
Each year dozens of children die after having some involvement with a CAS in the last year of their life, though most deaths are natural or deaths of infants due to unsafe sleeping environments.
Last year there were 107 such deaths, and of those 17 children were in CAS care at the time of their death, according to statistics from the coroner's pediatric death review committee. One case was classified as a homicide.
A bill introduced by the NDP's critic for children and youth services to allow the ombudsman oversight of children's aid societies passed second reading in the Ontario legislature in the spring.
Monique Taylor is hoping it will become law.
"There needs to be this oversight and somebody who has the teeth and who people trust," she said. "People trust (the ombudsman) to come back with a fair decision and I think that's the biggest thing."
Complaints about children's aid societies can go to the Child and Family Services Review Board. But the ombudsman said it doesn't have the powers and public accountability his office does.
"They don't take complaints about how the CAS actually makes their decisions," Marin said. "They take complaints about how the CAS have handled complaints so it's a very circuitous way to be involved in the system. They have no direct investigative ability to look into substantive decisions."
The minister of Children and Youth Services said that mechanisms are in place to ensure every decision is reviewable.
"The ministry requires all children's aid societies to have clear, transparent and consistent complaint review procedures," Teresa Piruzza said in a statement.
The ombudsman already has the authority to investigate complaints about the Child and Family Services Review Board, she said.
In addition to the board, there are internal CAS review processes, the family court system and the Office of the Children's Lawyer, which provide a measure of oversight.
The provincial advocate for children and youth said there is no mapping of a true oversight system that "interlocks all the parties in terms of roles and ability to do their job."
"I support the ombudsman having a role in having oversight of child welfare," Elman said. "It's a much bigger process than one body. But would the ombudsman be able to contribute to improving child welfare? I think so."
The executive director of the Ontario Association of Children's Aid Societies said while there are a significant number of oversight mechanisms in place, the system is not perfect.
"Several of the complaint processes can be duplicative for families so they have to go here and there but there's also maybe some gaps," said Mary Ballantyne.
"Our hope really is to be able to engage in discussions about whether the ombudsman oversight could provide some improvements to the system. What we would be most concerned about is just adding another layer on top of the existing processes."
At the same time, children's aid societies are dealing with funding shortfalls, Ballantyne said. An OACAS report found that as of September 2012 there was an estimated gap of $67 million between the amount of funding allotted and the amount needed by children's aid societies to deliver child protection services.
The minister said in a statement that funding to children's aid societies has been increased by about 40 per cent since 2003-04 to $1.5 billion and earlier this year the government invested about $70 million to clear historical debts and in-year deficits.
"Moving forward, we are working with the CAS's to help ensure they can manage within their budgets," Piruzza said.