Can Canada’s child-protection systems be fixed to prevent horrific abuse?

As details of Jeffrey Baldwin's horrible life and death emerge in a Toronto coroner's court this week, we're hearing about yet another lapse in Canada's child-protection system.

The case of a B.C. aboriginal child sent to live with relatives in Saskatchewan, where she nearly starved to death, is strikingly similar to what happened to five-year-old Jeffrey. He ended his days in 2002 in a squalid room in his grandparents' house weighing just 21 pounds. Doctors said his emaciated body resembled that of an African famine victim, The Canadian Press reported.

His grandparents were later convicted of second-degree murder.

The little girl in the B.C. case was also in the care of her grandparents in Regina after being placed there at age two by B.C.'s Ministry of Children and Family Development in 2007.

According to a report by Mary Ellen Turpel-Lafond, B.C.'s representative for children and youth, the child had bounced around several B.C. foster homes before being set to her grandparents on the prairies and transferred on the recommendation of Saskatchewan's First Nations Child and Family Service agency.

[ Related: Much-delayed Jeffrey Baldwin probe prompts question about the value of inquests ]

When she was rescued 18 months later, after a suspicious neighbour in the small First Nations community called police and child-welfare workers, the little girl was found starving and neglected.

"The girl had been confined to a dark furnace room in the basement of the home, separated from the other children living there," Turpel-Lafond's report says.

"She was severely emaciated, suffering from malnutrition as well as a number of injuries including an untreated fracture of the clavicle, bruising and scars on her head."

The grandparents were convicted last year of child neglect and sentenced to three years in prison.

The report hammers B.C. child-welfare authorities for failing in their primary responsibilities to the girl. They didn't do their own home study and didn't follow up on the sketchy criminal-records check forwarded by the First Nations agency. It turned out the grandfather had some 70 convictions and the couple was known to abuse prescription drugs.

Turpel-Lafond also criticized Saskatchewan's Ministry of Social Services for failing to ensure the First Nations agency complied with provincial standards of child-welfare practice, "which resulted in the child's safety being compromised."

"While the [First Nations] agency was delegated by the Saskatchewan ministry to provide child welfare services in this community, the ultimate responsibility for these services rested with the ministry," the report said.

[ Related: Inquest into starvation death of five-year-old boy hears from foster parent ]

The commissioner recommended changes to the way the B.C. ministry does things, including its protocols when dealing with other provinces and territories, but also advised Saskatchewan's child-protection authorities need to do a better job.

CBC News pointed out that Turpel-Lafond also urged Ottawa, which has responsibility for First Nations people on reserves, to take a more active role in monitoring the well-being of aboriginal children under provincial care.

“Uniform standards must be applied across the country so that this doesn’t happen to another child in the future," the commissioner said.

Saskatchewan Social Services Minister June Draude said the government accepts Turpel-Lafond's findings and has been working to fix the problems she identified.

"It is a horrific tragedy whenever a child is abused or neglected at the hands of their caregiver," Draude said, according to CBC News. "Tragedies like this are heartbreaking and warrant our utmost attention, along with action to try to prevent this from happening again."

The problem is, horror stories like this always seem to be followed by official expressions of regret and promises to do better.

In the 1990s, retired B.C. judge Thomas Gove chaired an inquiry into the death of five-year-old Matthew Vaudreuil, who was smothered by his troubled mother after evidence he'd been tortured, beaten and starved.

The Gove report revealed shocking failures by the family's case workers and others who seemed to work in isolation while Matthew was abused and eventually killed. Gove recommended reforms and there were promises to implement them.

Yet, here we are again. The same lax oversight Gove highlighted is evident in Turpel-Lafond's latest report. A 2008 editorial in the Vancouver Sun referenced several other cases since Gove's report that show the system continues to fail children, especially in remote areas.

"We don't want to read any more reports about children who might be alive today if those who were supposed to protect them had paid more attention," the five-year-old Sun editorial concludes.

The same kinds of problems show up in the Baldwin case, and other Ontario cases before it.

[ Related: Child protection changes needed: coroner ]

The Catholic Children's Aid Society, which gave legal custody of Jeffrey to his neglectful grandparents, found no treason to follow up with the family as their were no protection concerns with the grandparents, The Canadian Press reported. This despite the fact they had previous child-abuse convictions.

Is institutional dysfunction simply built into the child-protection system in Canada?

Is it a problem of inadequate funding, of burned-out social workers carrying too many files, of layers of bureaucracy that often don't talk with each other?

It's probably a combination of all those and other factors. The real question is, how many Matthew Vaudreuils and Jeffrey Baldwins will there be before things really change?