The lawyer for the Children's Aid Society of Toronto told a coroner's jury looking into the death of Katelynn Sampson said Monday all the institutions that were involved in the seven-year-old's life were too slow in revising their opinions about the child's guardians.

"You need to encourage critical thinking," Mark Freiman told the inquest into the girl's death .

In the inquest's last day to hear recommendations, Freiman asked the jury to recommend expanding a supervision model implemented at Toronto CAS in response to Katelynn's death. The idea would be to provide a second pair of fresh eyes to the cases the Society oversees, "not as a means of discipline but rather as a means of introducing different perspectives to think of things," he said.

Katelynn 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.

The couple, Donna Irving and Warren Johnson, pleaded guilty to second-degree murder in 2012 and are now serving life sentences.

The Office of the Children's Lawyer began the last day of presentations to the coroner's jury by recommending the UN Convention of the Rights of the Child be incorporated into the province's Child Services Act.

The office provides legal representation to kids under 18 when it comes to custody, access and child protection cases.

"A number of Katelynn's rights as a child were denied: her right to life, her right to be free from violence, right to education, right to care, right to maintain relations with her mother ... and the one that loomed large, the right to be heard," Caterina Tempesta, the lawyer for the office, told the five-member coroner's jury.

She said the office supports many of the recommendations put forward Friday by the Office of the Provincial Advocate for Children and Youth including:

  • Amending the Child and Family Services Act to ensure a child's views are taken into account when it comes to custody cases.
  • Asking the Ministry of the Attorney General to consult on how to improve a child's participation in the family court process.
  • To ensure child protection agencies and police record checks are done for every person who lives in the home, not just the legal guardian.

In November 2015, seven years after the girl's death, a coroner's inquiry was launched to examine whether the public agencies involved could have done more to protect Katelynn, whose mother Bernice Sampson was unable to care for her while she battled a drug addiction.

Sampson's lawyer Suzan Fraser has argued before the jurors that the 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."

Agencies under scrutiny

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."

Both the Children's Aid Society and Native Child and Family Services were contacted about either Katelynn or about Irving and Johnson while she was living with them. Oversight was transferred to the latter agency because of Irving's aboriginal heritage.

The inquest has heard that one caseworker made several attempts to have the agency investigate after finding Katelynn in the home. But Irving's file was quickly closed after she lied and said Katelynn had gone back to live with her mother. 

Katelynn-Sampson

In August 2008, Katelynn died from complications of blunt force trauma including septic shock after months of beatings. Her legal guardian Donna Irving and her boyfriend Warren Johnson pleaded guilty to second-degree murder.

Months later, Irving called the Children's Aid Society saying she no longer wanted the child. The call was transferred to Native Child and Family Services. It took a case worker 16 days to contact Irving, but by then she said she was getting help from Katelynn's school, which wasn't true. 

The Children's Aid Society also raised concerns after a record check found allegations of sexual abuse against Johnson, though no charges were laid. Another call about Katelynn came in to the Children's Aid Society about a month later, but the record got lost and it was never addressed.

Native Child and Family Services said Monday it would like to see verified allegations of child abuse automatically submitted and included in the Child Abuse Registry, and verified abusers automatically red-flagged on the registry.

It also told the jury it wants the registry accessible to all agencies and ensured that all the agencies check the registry when dealing with all potential guardians.

Irving and Johnson were granted custody of Katelynn despite having criminal convictions and a history with child welfare agencies.

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.

One of her teachers told the jury she regrets not calling authorities when she saw bruises on the seven-year-old

"We all know there was a failure here because a seven-year-old child is dead," said Wendy Lopez, the lawyer for the Toronto District School Board on Monday.

She said the TDSB has made improvements to protect kids since Katelynn's death including improved training of teachers and staff when it comes to abuse and stricter policies to track and report students' absences.

Recommendations 

The role of an inquest is twofold: to inform the public about the circumstances of a death, and to issue recommendations to prevent others from dying in similar circumstances.

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.

The jury may accept, change or reject them in issuing its own report at the end of the inquest.

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 the city's four overlapping child welfare agencies has been a recurring theme at the inquest.

The jury's conclusions, however, will be non-binding. 

With files from Canadian Press