A seven-year-old Toronto girl was overlooked and ignored by those who had the duty to save her and died as a result of their "significantly flawed decision making," a coroner's inquest heard Friday.
Despite gaps in their files, child protection workers at two agencies had all the information they needed to rescue Katelynn Sampson from her abusive guardians, the lawyer representing the girl's mother, Bernice Sampson said.
"I question the need for more and better information when what they needed was right in front of them," lawyer Suzan Fraser said.
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Officials at the girl's school also knew enough to intervene, given Katelynn's noticeable injuries and prolonged absences, Fraser said.
Though they called child welfare authorities five times, "they could have done more," she said.
And at no point did anyone ask Katelynn how she was doing or what she wanted, Fraser said in her closing submissions to the jury.
"Her death was not inevitable...there were opportunities to alter the course of her life, to see her, to speak with her," she said. "Katelynn did not have to die."
The coroner's counsel said in her submissions that Katelynn was "unseen and unheard" by those whose job it was to ensure her safety.
"So many agencies and institutions circled around her and yet remained peripheral while Katelynn was a ghost at the centre," Nicole Bailey said.
"It should have been simple -- Katelynn should have been the focus, the heart."
After hearing from 37 witnesses over four months, jurors on Friday received a series of proposed recommendations from lawyers in the case, including more than 30 supported by all parties.
One proposal involved the creation of Katelynn's Principle, a doctrine meant to ensure children are "at the centre" of the child welfare system.
Another would see all four Toronto child welfare agencies adopt a shared intake service with a single phone number and location.
The sharing of information between child welfare agencies has been a recurring theme at the inquest, but Fraser said they simply didn't use the knowledge they had, with tragic results.
Katelynn Sampson was beaten for months until she died of complications from her injuries. Her battered body was found early on Aug. 3, 2008, in the apartment of a couple who were supposed to be caring for her.
Donna Irving and Warren Johnson pleaded guilty to second-degree murder in her death. Katelynn's mother, Bernice, was addicted to crack and gave her daughter to Johnson and Irving in a misguided attempt to
give Katelynn a better life.
The inquest heard that several agencies, including the Children's Aid Society, missed opportunities to help Katelynn before her death despite knowing her guardians had previous criminal convictions.
Referring to a picture drawn by Katelynn of a little girl in a dress with a wand and flowers, Fraser told the jury: "Take the wand out of the picture, do your magic and make sure it never happens again."