Watch the video above: Minority of recommendations from coroner’s inquests ever implemented. Cindy Pom reports.
TORONTO – 432 inquests, 2,689 recommendations. Yet, the numbers don’t appear to add up to much change following coroner’s inquests in this province.
Of those 2,689 recommendations, only 29 per cent – 740 – have been implemented, according to the Office of the Chief Coroner of Ontario. Another 8 per cent will be implemented and a further 8 per cent were implemented with changes. All of the recommendations are voluntary.
Just last week, the jury in the Jeffrey Baldwin inquest issued 103 recommendations.
Jeffrey was placed in the care of his grandparents, Elva Bottineau and Norman Kidman. The Catholic Children’s Aid Society did not run background checks which would have shown the pair were convicted child abusers.
“The system needs to be opened up to a public inquiry and we need to discuss, as a province, how this can be changed or there will be more Jeffrey Baldwins,” said Irwin Elman, the provincial advocate for children.
Baldwin was placed with Bottineau and Kidman as a baby. When he died just before his sixth birthday, he weighed little more than a 10-month old infant. He’d been starved, forced to drink toilet water and locked in a cold bedroom.
The jury’s recommendations are aimed at closing the gaps in the province’s child welfare system that led to Baldwin’s death.
One of the recommendations made was the implementation of the Child Protection Information Network (CPIN) – a database that would allow children’s aid societies across the province to access each other’s information.
“It’s certainly frustrating. The whole idea of this database is at least 11 years old and we’re six years away according to the ministry,” Elman said. “Seventeen years to put something into practice which is really common sense. And it’s not that complicated, we can do this.”
A recommendation to create a database was originally made following three inquests in 1997 and another in 2000. But it has not been implemented yet.
The province says it is working on it however and expects it to be rolled out to seven agencies by this summer. The Baldwin inquest jury members want to see it across the province within 2 years.
Dr. Dirk Huyer, the interim chief coroner for Ontario, told Global News in an interview Monday that the jury members aren’t able to become experts in child welfare. As a result their recommendations are then reviewed and decided upon by a second group of people.
“So they’ll highlight an issue through their recommendation and believe that they’ve got a solid idea on how to fix that problem,” he said. “But it’s up to the experts in the organization to understand how the recommendation may or may not be something that can be implemented.”
Baldwin’s grandparents had been convicted of child abuse multiple times before Jeffrey was put in their care. Bottineau was convicted after her first child died, while Kidman was convicted after two of Bottineau’s other children were sent to hospital following a beating.
Read More: The key recommendations in the Jeffrey Baldwin inquest.
May McConville, the executive director of the CCAS in Toronto admitted the province’s child welfare system had a “collective blind spot around extended family” at the time.
And some of the recommendations aim to remedy that “blind spot.” One of the recommendations made by the Baldwin jury suggest kinship service standards require yearly home visits to children aged five and under who are living with alternate caregivers like grandparents when the case has already been closed.
It’s another recommendation which sounds familiar. Following an inquest in 2000, the jury members recommendeded “unannounced home visits” as part of the supervision for all cases.
It’s not known how many, if any, of the Baldwin recommendations will be implemented.
– With files from Cindy Pom
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