Much-delayed Jeffrey Baldwin probe prompts question about the value of inquests

An inquest into the horrible death of five-year-old Jeffrey Baldwin is underway in Toronto and the hearing is already getting stomach-churning evidence of neglect.

Baldwin died more than a decade ago, but the inquest was delayed because of the time it took to convict his grandparents, Norman Kidman and Elva Bottineau of second-degree murder, and their subsequent appeals. Bottineau took her conviction all the way to the Supreme Court of Canada, which last year decided not to hear the case.

The little boy died in November 2002 of pneumonia and starvation in a locked room that reeked of urine and feces while his grandparents and other children in their care watched television in the next room. He weight just 21 pounds.

Kidman and Bottineau were given custody of Jeffrey by the Catholic Children's Aid Society of Toronto despite Kidman's previous conviction for child abuse.

[ Related: Chronology of Jeffrey Baldwin fatal child abuse case ]

The inquest, which is expected to last three months, will likely come up with a set of recommendations in hopes of ensuring something like this doesn't happen again.

Some people might be forgiven for asking, what's the point?

Across Canada, inquests are held into deaths in all kinds of circumstances, from custody-related cases like this one to construction site accidents. A jury (usually six citizens) will make recommendations arising from the evidence, not to lay blame but to help mitigate the chances of a similar death.

But how effective are inquests in pushing governments and their agencies into action?

When it comes to the deaths of children in Ontario, the record is mixed. A look at the provincial Advocate for Children and Youth's inquest database shows recommendations were implemented, stemming from 19 out of 26 inquests into the deaths of young people from 1995 to 2012. That includes 14 inquests related to child welfare-related deaths like Jeffrey Baldwin's.

But the Toronto Star reported in January that hundreds of other key recommendations connected with the deaths of children in provincial care were never implemented.

The Star said child-welfare agencies are shielded from public scrutiny once an inquest ends through privacy legislation. The children's advocate is forced to keep information that might identify a child secret, which makes it hard for the public to know how agencies responded.

“It’s bizarre,” advocate Irwin Elman told the Star. “While the inquest has been public and the record is public, I cannot identify the person publicly and must even go so far as to not identify agencies.”

When it comes to all inquests conducted by the Ontario Coroner's Service, a report issued last year found the number of inquests annually ranged from 57 to 80 from 2004 to 2010, with recommendations averaging between roughly five and 10 per hearing.

When it came to implementation (agencies are required to report back within a year) of those recommendations, approximately 33 to 42 per cent of them were implemented between 2004 and 2008. That rate drops off to 14 per cent the following year, then nine per cent in 2010. A small percentage were still to be implemented, or sometimes alternative recommendations were substituted, bringing the totals to upwards of two thirds in almost every year except 2010.

Few recommendations were rejected outright, the report's data suggest, and almost none rejected due to lack of resources.

Elman told the Star the January launch of the inquest database would help make government agencies more accountable. Many of the recommendations found in the child advocate's database were made repeatedly by different coroner's juries, the Star noted.

“This database is us saying that as a province we owe it to the children who have died. This is their legacy,” he said. “I hope it pushes all the sectors towards taking these recommendations seriously.”

[ Related: Ontario ombudsman says Toronto police lack public trust after Sammy Yatim shooting ]

The same issue has arisen in the wake of the police shooting of teenager Sammy Yatim in July.

Ontario Ombudsman Andre Marin has launched an investigation into the government's direction regarding methods of defusing dangerous situations without force, citing numerous inquests in police-involved deaths.

"In the last week we've looked at the results of inquests dating back to 1994, almost 20 years, and the recommendations coming out of these inquests are almost carbon copied from each other - increase police training, increase how police diffuse situations," Marin said in announcing his inquiry last month, according to QMI Agency.

"Have they been gathering dust in some bin somewhere? It seems to be like Groundhog Day. Inquest after inquest, police shooting after police shooting,"