The jury in a coroner's inquest into the starvation death of a Toronto boy at the hands of his grandparents is now considering its recommendations.
The jury in the Jeffrey Baldwin inquest heard from more than 50 witnesses and has more than 300 exhibits to consider.
Jeffrey's grandparents kept him locked up for long stretches of time in a cold room with his own waste and chronically starved him.
He was a healthy baby when the Catholic Children's Aid Society in Toronto placed him with his grandparents, but by the time he died at age five, he weighed about the same as on his first birthday.
The CCAS didn't discover files in their own records indicating that both grandparents were convicted child abusers until after Jeffrey's death.
"The system failed Jeffrey, the system failed his siblings," said lawyer Freya Kristjanson, who represents the Baldwin siblings.
She's asking the jury to recommend better training for new workers, so they will "recognize signs of neglect."
Others are calling for a public inquiry.
"We haven't had a good hard, long look at how we actually work as a province to protect children, and that's something we really need to do in a public way," said Suzan Fraser, a lawyer for the Provincial Advocate for Children and Youth.
Among the recommendations the jury has been asked to consider is one urging the Ontario government to allow children's aid societies to access each other's child protection records. The jury can accept, reject, or come up with its own recommendations.
In her closing remarks, Crown counsel Jill Witkin told the jury they must, "shine the light of scrutiny on government and institutions and that light cannot fade, like Jeffrey's did."