Margarita Quintana doesn't recall many details about the case of Jeffrey Baldwin, a five-year-old boy who starved to death at the hands of his grandparents eleven years ago.
But what the frontline children's aid worker does remember is that the boy's grandmother, Elva Bottineau, appeared at the time as reliable pillar of support at the centre of a troubled family.
Speaking softly, with multiple pauses for thought, Quintana repeatedly told an inquest into Jeffrey's death Thursday she had no concerns about Bottineau, which was why she never carried out a records check on the grandparents.
"They were highly involved with the family. They were always concerned about the children," said Quintana, who's now retired from the Catholic Children's Aid Society.
The inquest has heard that both Bottineau and her partner Norman Kidman had a history of child abuse, including separate convictions and various dealings with the children's aid society.
But a lack of records checks — an issue which lies at the heart of the inquest — meant children's aid workers didn't look through their own files to discover disturbing details of the pair's past until after Jeffrey's death.
Jeffrey was so severely starved at the end of his life that he couldn't lift his own head. He was just 21 pounds when he died in November, 2002 — about as much as he weighed on his first birthday.
The inquest has heard how Bottineau and Kidman kept Jeffrey and one of his sisters locked away in a cold, filthy room, where they were left to urinate and defecate and then forced to clean up their own mess.
Grandparents favoured over birth parents
But to Quintana, more than a decade ago Bottineau and Kidman appeared to present a better care alternative than Jeffrey's parents, who were described as a young "high-risk" pair who struggled with domestic violence issues.
"The conflict between them was almost every day, every week. And we were not seeing any changes," she said of Jeffrey's parents. "Our concern was their poor parenting skills. Not understanding the..state of their children."
Quintana described how Jeffrey's parents didn't show up for support programs and counselling sessions. The inquest also heard about an instance when workers at a welfare office saw the young couple violently shaking their children.
Jeffrey's father had anger management issues and his mother was "overwhelmed" with caring for her children, Quintana said.
Meanwhile, Bottineau and Kidman, who were already caring for Jeffrey's oldest sibling by the time Jeffrey was born, appeared far more stable.
"I saw the quality of care they were providing for sibling one. Also I knew their house. Always it was clean. It was appropriate," said Quintana, adding that Bottineau even once called CCAS with concerns about violence displayed by Jeffrey's father.
Quintana noted she didn't suggest Jeffrey and his sister be handed over to Bottineau — that idea came from Jeffrey's parents when CCAS was considering apprehending the kids — nor did she suggest Bottineau ultimately seek permanent custody of the children.
But she said "there were no concerns" about Bottineau caring for the children, and after the grandmother sought custody of the kids, the CCAS dropped efforts to get a supervision order.
Birth mother cited 'normal' family
Quintana also told the inquest that Jeffrey's mother spoke highly of Bottineau and never raised concerns about her family history.
"She was always saying how normal was her family," Quintana said.
Jeffrey's mother has testified at the inquest, however, that she and Bottineau — who kicked her out of the house at 16 — did not get along.
She also testified that had she known about her mother and father's past, she would not have consented to her children being placed in their care.
The inquest has heard two different psychological evaluations cast major doubts on Bottineau's ability to care for children. It has also heard that Bottineau had two children from a previous relationship who were taken out of the home and made Crown wards following a severe beating by Kidman that landed them in hospital.
Jeffrey's mother told the inquest she didn't know any of those details.
After listening to Quintana's testimony on Thursday, Irwin Elman, Ontario's advocate for children and youth, said it seemed CCAS didn't make the effort to vet Bottineau thoroughly because she was seen as an easily available care alternative.
"It seems to me that the grandmother Elva was the convenient choice, but not the only choice," he said outside the inquest.
"(Quintana) missed so many opportunities to protect those children...(CCAS) looked for the evidence that would support their plan. They didn't look for anything else. That's not what we expect of child protection."
The coroner's inquest is not looking to assign blame, but rather is exploring systemic issues surrounding Jeffrey's death.
Quintana's testimony is set to continue on Monday.