Canada: Coroner’s Jury Recommendations Into Death Of Jeffrey Baldwin

Last Updated: September 12 2014
Article by Maria Gergin

Most Read Contributor in Canada, November 2017

In February 14, 2014, a Coroner's Jury looking into the death of Jeffrey Baldwin, a five-year-old Toronto boy who starved to death in 2002 while in the care of his grandparents, released 103 recommendations. A number of the recommendations made by the jury pertain to ways in which Ontario school boards can work to improve the identification and protection of children who are subjected to abuse and neglect.

In 1998, Jeffrey was taken by the Catholic Children's Aid Society from his teenage parents, both of whom were emotionally volatile, and he and his siblings were placed in the care of their grandparents. Both of Jeffrey's grandparents had previous convictions for child abuse, but those records weren't discovered in the Catholic Children's Aid Society's own files until after his death in 2002. The family's caseworker testified that she never conducted any record checks on Jeffrey's grandparents, as she perceived them to be reliable and supportive in comparison to Jeffrey's own parents.

In March 2003, Jeffrey's grandparents were arrested and charged with first-degree murder for their role in his death.


One of the findings of the inquest relating to Jeffrey's case was that his death was the result of systemic failure, rather than the failure of any one party. As such, the jury's recommendations target a number of ministries, including the Ministry of Children and Youth Services, Ministry of the Attorney General, the Ministry of Health and Long-term Care, the Ministry of Education, the Information and Privacy Commissioner of Ontario, and various children's aid societies.

Some recommendations are focused on improving record keeping and information sharing among children's aid societies in Ontario, including urging the government to implement the Child Protection Information Network, a province-wide system accessible by any children's aid society in the province in the next two years. The jury has also recommended that the Ministry of Children and Youth Services conduct and fund a review of all child protection standards, including the provincial kinship service standard.


The jury has made a number of specific recommendations directed at the Toronto District School Board (the "TDSB"), which are partly the result of evidence presented at the inquest regarding the role the TDSB could have potentially played in Jeffrey's case. Specifically, the jury was presented with evidence that one of Jeffrey's sisters, who was abused by his grandparents like Jeffrey was, most likely only survived the abuse because she was allowed to go to school, where she was given a small snack every day. The evidence suggested that Jeffrey was not attending school at the time of his death because he was not toilet trained. The jury was also presented with evidence that some of Jeffrey's sister's teachers were unaware of their duty to report suspected abuse or neglect to children's aid.

In the context of the above-noted evidence, the jury recommended that prior to the start of the 2014-15 academic year, the TDSB review and update its P045 (Dealing With Abuse and Neglect of Students) and PR560 (Operational Procedure – Abuse and Neglect of Students) policies in consultation with Toronto children's aid societies, the Ministry of Children and Youth Services and Ontario Association of Children's Aid Societies.

The jury recommended that the TDSB deliver a directive to principals and staff that where a member of staff suspects that a child may be in need of protection, as defined in the Child and Family Services Act, R.S.O. 1990, c. C.11, and current TDSB policies regarding abuse and neglect of students, the staff member has a legal obligation to report directly to a children's aid society. The directive should also confirm that the staff member should not investigate or discuss the concern prior to making the call to the children's aid society. As part of the identification of potential cases of student neglect and abuse, the jury's recommendations encouraged the TDSB to develop attendance alerts for students who are consistently absent or who are absent for prolonged periods of time.

The jury also recommended that the TDSB implement annual training for all of its staff, including teachers, administrators, trustees and all office staff and educators, on the duty to report child abuse and neglect, including how to recognize it, report it, and how to manage the consequences of making a report. The TDSB was also encouraged to implement a policy or procedure to take effect in the 2014-5 school year requiring that a Vulnerable Sector Screening (VSS) be completed for all volunteers, with an updated VSS to be completed by each volunteer no less than every 5 years.

The jury also recommended that the TDSB implement a procedure to address barriers, such as toilet training, faced by children who are eligible to be enrolled in school but are not yet required to attend, in order to encourage their enrollment in school. The jury recommended that the TDSB liaise with community partners, such as libraries, religious and community centres, and children's aid societies in developing this procedure and addressing barriers.


The jury made a number of recommendations for the implementation of policies by the Ministry of Education (the "MOE") in order to ensure a uniform approach to dealing with student abuse and neglect across school boards. Most notably, the jury recommended that the MOE review all of the recommendations the jury directed at the TDSB and consider whether they should be applied at other school boards across the province.

The jury recommended that the MOE include definitions of "abuse" and "neglect" in appropriate policies and documents to improve the identification tools provided to educators and staff in its school boards.

Significantly, the jury encouraged the MOE to conduct a review of the Ontario Teacher's College's curriculum and teacher training, to ensure that the College adequately covers training in identifying abuse and neglect in children and the duty to report.

Also significant was the jury's recommendation that the MOE consider incorporating into the Physical and Health Education curriculum the requirement that students from Kindergarten to Grade 12 be educated about neglect in an age-appropriate manner.

The jury also suggested that the MOE play a role in obtaining information about students' guardians and relatives, by incorporating student sibling and family composition information as part of the standard MOE student registration forms.


The Baldwin inquiry and recommendations confirm that all employees of school boards have a special role and responsibility in the protection of children and students of all ages.

School boards should ensure that all educators and staff receive appropriate and frequent training with respect to school board policies and procedures on the identification and reporting of student abuse and neglect.


In Ontario, the Child and Family Services Act places a general duty on people, including any person who performs professional duties with respect to a child, to report the abuse and neglect of a child to a children's aid society. Any member of school staff has a duty to report suspected abuse or neglect "forthwith" once he or she has reasonable grounds to suspect that the child is in need of protection.

Notably, it is not the duty of the teacher or principal to assess the severity of the abuse – it is mandatory for teachers and principals to report any and all cases where there are reasonable grounds to suspect that abuse has occurred, regardless of whether the injury is minimal. It is also not the role of the principal to fully investigate or to confirm whether, in fact, abuse has occurred, subject to the minimal investigation necessary in order for the educator to determine whether reasonable grounds exist to suspect that abuse has occurred. A full-scale investigation should be left to the police and/or children's aid society.

While the duty to report lies with the staff member who formed the suspicion or heard the disclosure, he or she may request the principal's or designate's presence while making the report to the children's aid society. Moreover, school board policies require that the principal be informed of the suspected abuse or neglect in writing, regardless of his/her participation in the call to the children's aid society. It must be stressed, however, that the responsibility to report is a personal one and that an educator is not required to wait or obtain the approval of the principal or designate before making a report.

Where a student raises a concern in school regarding possible abuse at home, or where home abuse is suspected on reasonable grounds, the school staff does not have control with respect to the removal of the possible offender.

As such, where a teacher or principal decides to take no action, the child may return home to an abusive situation. In this regard, where suspected abuse involves family members or someone in the student's home, it is particularly crucial that the suspected abuse is reported as quickly as possible.

Finally, whenever an educator receives information that causes him or her to consider whether a report should be made to the children's aid society, the school should review its obligations under the relevant police/school board protocol. In general, incidents involving violence or an imminent threat to the safety and security of the school community will also require a police response.

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