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Elman Wants a Real Inquest

February 7, 2014 permalink

Fixcas has so far paid little attention the the Jeffrey Baldwin inquiry. Following the pattern of past inquests we can expect lots of testimony of tragic failures, followed by a long list of recommendations all suggesting more money and power for children's aid.

Ontario's provincial children's advocate Irwin Elman, through his legal counsel Suzan Fraser, has introduced 37 suggestions for jury findings. The first 35 are for more bureaucracy. These cannot improve the lives of children in a system suffering from too much bureaucracy. But Elman's last two suggestions are something new. He wants a public inquiry into the protection of children in the province. One staffed not just by the same people who created the systems in the first place or those who currently work in the system. The inquiry shall have the power to access information from witnesses and require the production of documents. In another recommendation, Mr Elman wants meaningful inquests into the deaths of children. An inquest into a death that conceals the name of the deceased more resembles a cover-up than a public inquiry.



Irwin Elman

My Office is an independent voice for children and youth. Our stake at Jeffery Baldwin's Inquest is to honour his young life and ensure the voice of children and youth are heard. Our goal, young people's goal, is to ensure that the safety, health and well-being of children and youth in Ontario is paramount. Change is hard and institutions like child welfare resist it. At the Inquest in our final submission we called for a Public Inquiry, a public, open transparent discussion into how we protect children and support families in this Province. Our statement is below. In their final submission the Catholic Childrens Aid Society said our submission was " grounded in hyperbole and sensationalism" Let them say it. A "leave it to the professionals" approach" , not this time. I do not care how hard it is to implement change, it needs to happen now before we have another Jeffery.

Source: Facebook, Irwin Elman


Jeffrey Baldwin inquest: Ontario’s Child and Youth Advocate calls for public inquiry into child protection

TORONTO, ON (February 4, 2014) – The Office of the Provincial Advocate for Children and Youth made its final submission today at the Jeffrey Baldwin inquest urging the jury to recommend a province-wide public inquiry into the protection of children in the province of Ontario. The following is a statement from Irwin Elman, the Provincial Advocate for Children and Youth:

“I urge the jury to recommend that the Premier of Ontario hold a public inquiry into the protection of children in Ontario to move the system forward. The examination cannot be held behind closed doors and it cannot be comprised only of the same people who created the systems in the first place or those who currently work in the system. It must be independent and involve the public, youth with lived experiences and others who can provide a fresh perspective.

After months of evidence, hearing about legislation, regulations, standards, policies, and best practices, we have to remember that this inquest is about Jeffrey Baldwin, a boy who was almost six years old, weighing under 22 pounds when he died of pneumonia as a complication of prolonged starvation like a ‘discarded little boy’. Much of the evidence we heard was about why people didn’t do things: there were no standards, it was not the practice at the time, there were no concerns and no red flags. The implication is that the system is different today, but despite what we have heard, I am not convinced that there has been significant change. That is why I am calling for a public inquiry into how we protect children and youth. Jeffrey’s death has been described as tragic, but so was his life. It is only due to Jeffrey’s death that we know about the locked rooms, the deplorable conditions and the deprivation. It’s not good enough that errors are only found and that changes are only made after a death. We expect and demand more. More from the child welfare system, more from the educational system, more from the neighbours, and more from the family who stood by and watched Jeffrey starve and die. We want a province where we have a care system that supports and nurtures children and families to be the best they can be and where every child is safe and protected. The coroner’s inquest into Jeffrey’s death must be a turning point. We can do better. We must act now.”

Source: Provincial Advocate (pdf)


  1. The Premier of Ontario call a public inquiry into the protection of children in the Province of Ontario. The inquiry shall have the power to access information from witnesses and require the production of documents. The inquiry will report publicly. The inquiry shall engage sectors which can offer points of protection to children and youth including schools, mental health sector, first responders, business, shelters that provide shelter to youth and families, doctors, hospitals, housing providers, psychiatrists, children’s aid societies, early years centres, parents and children and youth with experience with the child welfare system as well as the general public. The inquiry will:
    1. review the investigation of child maltreatment, child protection practice, and child protection policy and procedure
    2. create a plan to ensure the health and well-being of Ontario’s children and youth that includes all sectors and which puts children at the centre
    3. consider the sufficiency of existing oversight mechanisms to ensure accountability of child welfare and the delivery of adequate services to children and youth including the role of the Ministry of Children and Youth Services (MCYS) and the capacity of volunteer boards of directors to provide accountability, oversight and the training and governance of workers and supervisors carrying out a legislated mandate under the CFSA
    4. examine Ontario’s child death review process for children who are connected to Ontario’s care systems within a year of their death and whether the criteria is sufficient to ensure meaningful review of the death of children connected to care
    5. review deaths which occurred in the last decade of children who were connected to Ontario’s care systems for which there are death investigation reports available
  2. The Ministry of Community Safety and Correctional Services and MCYS, together with the Office of the Chief Coroner for Ontario and the Office of the Chief Forensic Pathologist for Ontario, create a task force to lead the development of a structured, open and transparent provincial child death review process for systematic reporting and analysis of all child and youth deaths and the evaluation of the impact of case-specific recommendations. The task force should include broad representation including representation from public health, the Canadian Pediatric Society, First Nations representation (e.g. Assembly of First Nations, Regional Chiefs or local Chiefs), young people, members of the general public, education, child care and child welfare and should consider:
    1. the composition of the child death review team
    2. the structure and process by which deaths are reviewed
    3. the creation of linkable databases for data collection, consolidation and dissemination, systemic data collection and data-sharing which would assist in the development and support of policy in Ontario and provide a model for other provinces
    4. the relationship with child death review teams from other provinces.

The report of the Task Force should be mailed to the jury, mailed to counsel for the siblings and the institutional parties with standing at the inquest, and placed on the Ministries’ websites.

Source: Provincial Advocate (pdf)