Not long after baby Jeffrey Baldwin was placed in the care of the grandparents who would ultimately starve him to death, a children's aid society worker looked at files on the couple's record of child abuse, a coroner's inquest heard Thursday.
But that information was not passed on to the workers directly involved in Jeffrey's care and the grandparents' shocking history didn't come to light at large until after the five-year-old boy died in 2002.
When he died, Jeffrey was a skeletal 21 pounds — about what he weighed when he was first sent to his grandparents four years earlier.
The missed opportunity in October 1998 was one of several the inquest heard about that could have exposed Elva Bottineau and Norman Kidman's sordid past and prompted children's aid to snatch Jeffrey and his three siblings out of their care.
The Catholic Children's Aid Society had, in its own files, records of Bottineau abusing her first child and of Kidman beating Bottineau's next two children from a previous relationship, sending them to hospital.
There were records of the CCAS supervising Bottineau and Kidman's care of the three daughters they had together. There were records of abuse investigations in the following years, including allegations made about some children Bottineau cared for as a "foster day mom."
The Catholic Children's Aid Society sent Jeffrey and two of his siblings (the York Children's Aid Society managed the file of Jeffrey's youngest sibling) to live with their grandparents when these files were a records search away.
The inquest heard Thursday from CCAS manager Louise Galego that common practice was to check internal records of the parents who were the subject of an investigation, not necessarily the grandparents as alternate caregivers.
However, Galego said, a records search for Jeffrey's mother, Yvonne Kidman, should have turned up the records of the supervision order she and her sisters were under when they were young. The file should "conceivably" have turned up, Galego said, but she couldn't say for sure if a search was ever done or not.
Those records would have noted that Yvonne Kidman and her sisters were under a supervision order after Bottineau's two older children were removed from the home following the severe beating by Norman Kidman.
One of those two children reported later that Bottineau and Kidman abused and neglected her and her brother, sometimes locking them in dog crates.
As an adult, she called the Catholic Children's Aid Society requesting old files about her, the inquest heard. That was just months after Jeffrey had been placed in Bottineau and Kidman's home.
The worker in the adoption department found those old records and mailed out copies, the inquest heard. But workers in the child protection department, who were dealing directly with the Bottineau-Kidman-Baldwin family, were never told, the inquest heard.
"The contact was not cross-referenced to the protection files," Galego said. "The process is very different today."
The CCAS has implemented many changes since Jeffrey's death, including various iterations of record-keeping systems, Galego testified. But gaps still remain, she said.
The society has changed its rules surrounding how thoroughly a grandparent or other relative can be checked out if the society is looking at placing a child in their care. But even today, there are limitations, she said.
If the society suspects a child is being physically abused by their parents and the authorities are looking at sending the child to their grandparents, the children's aid society is not permitted to check records on the grandparents beyond what's in the society's own files without their consent, the inquest heard.
The internal records check should turn up any past involvement the grandparents have had with that children's aid society.
But it won't reveal if any other children's aid society has ever intervened with the family, the inquest heard. There are more than 40 children's aid societies in Ontario, covering different regions, religions and cultures.
Galego said it would be "extremely beneficial" if workers had more access to Fast Track, a provincial database containing basic information of the names of people who have had involvement with children's aid societies across Ontario.
A new system, the Child Protection Information Network, slated to start rolling out in April 2014, promises to do that, though workers still don't know the ins and outs of how it will function, Galego said.
"We are very hopeful with the introduction of the CPIN," she said. "But such a system will require significant resources."
But records checks, both internal and external, rely on names, the inquest heard. Files are usually opened under the mother's name and workers are dependent on the name someone gives them. If a woman was recently married and gives a worker her new name, the children's aid society may not discover a file under her maiden name, the inquest heard.
Bottineau went by variations on the spelling of her first and last names, the inquest has heard. The current systems should pick up files for "Alva Bottineau" when "Elva Bottineau" is searched, for example, but may not find "Elva Kidman."
After Jeffrey's death the emergency children's aid worker recorded the grandmother's name as Elva Kidman, and it wasn't until five days later, when she identified herself at a court hearing to keep custody of the other three kids as Elva Bottineau that workers searched for records under that name and pulled up a disturbing history.