It took almost 12 years and about five months of witness testimony, presentations and exhibits to learn from the tragic death of Jeffery Baldwin.
Baldwin was a healthy baby when he and his siblings were placed in the care of their grandparents, but when he died just shy of his sixth birthday his weight was that of a 10-month-old infant.
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 four-person jury at the coroner's inquest into his death delivered 103 recommendations Friday.
Many of the recommendations focus on the need to improve record keeping and information sharing between children's aid societies in the province, something the director of the Catholic Children's Aid Society Mary McConville says is "the largest present systems flaw."
To the Government of Ontario, they recommend delivering on its pledge to implement the Child Protection Information Sharing Network (CPIN) within two years.
McConville says the CCAS and about a dozen other agencies will be online with the single information system in the coming year. She expects the rest of the agencies will be on board within two years.
The jury suggested the province should also explore the possibility of amalgamating Ontario's 46 children's aid societies.
The duty to report child abuse or neglect was also prominent in the recommendations.
The jury recommended an awareness campaign aimed at letting members of the public know about their duty to report child abuse or neglect and how to spot the signs.
They went further though, asking the Ministry of Children and Youth Services to introduce penalties for non-professionals who have direct knowledge of child abuse but don't report it.
This recommendation likely stems from the fact that, aside from Jeffrey's grandparents, there were four other adults living in the home - Elva Bottineau and Norman Kidman's two adult daughters and their partners.
"I felt that there were many adults that failed to report the well-being or whatever was happening to Jeffrey in that home," Osiris Villalobos told reporters outside the coroner's office.
The day Jeffrey Baldwin died, Villalobos went to the home and took Jeffrey's siblings out.
The jury also suggested that placing a child in the care of a relative should not be the end of the road for children's aid societies, recommending annual home visits after the file is closed in cases of children five and under who are living with alternate caregivers.
The jury is also recommending 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 inquest jury also issued a verdict of homicide, which in an inquest setting means another person contributed to his death.
The finding was expected, as the boy's grandparents, Elva Bottineau and Norman Kidman, were convicted of second-degree murder.
Jeffrey's parents were barely out of childhood themselves when they had four kids in quick succession, and nearly as swiftly they were taken away by children's aid and handed over to the grandparents.
The family's caseworker testified that she had no concerns about Bottineau, who she thought was a reliable pillar of support when compared to Jeffrey's often-volatile teenage parents, so she never conducted any records checks on her or Kidman.
Had those checks been done, workers would have found a disturbing history of child abuse.
After Bottineau's first baby died of pneumonia in 1969 doctors found multiple untreated fractures and she was convicted of assault causing bodily harm.
Two different psychological evaluations cast major doubts on Bottineau's ability to care for children.
Bottineau then had two more children, who were made Crown wards following a severe beating by Kidman that landed them in hospital. He was convicted of two counts of assault causing bodily harm.
Those two children later alleged horrific abuse and neglect, including being tied to their beds and locked in dog crates.
After those two kids were removed from the home, the Catholic Children's Aid Society supervised Bottineau's care of her and Kidman's three daughters for a time.
Bottineau testified at the inquest and said she was having a hard time with Jeffrey, who she described as having a "slow learning ability.''
Once she got permanent custody of him in family court Jeffrey was essentially hidden from the rest of the world. He was not enrolled in school because he was not toilet trained, Bottineau said.
Jeffrey had not been taken to a doctor since he was 18 months old, the inquest heard.
Dr. Stanley Zlotkin studied Jeffrey's autopsy photos and deemed them like nothing he had ever seen, despite having worked at the Hospital for Sick Children since 1980 and having done work in Africa.
"Jeffrey was literally skin and bones,'' he wrote in a report. "This child was likely chronically starved of food. There is no alternative hypothesis to explain the severe wasting and stunting.''
Many changes have already been made in the child welfare system since Jeffrey died in 2002, but all parties agree there is more to be done.
Standards for kinship care were overhauled in the wake of Jeffrey's death and the CCAS maintains that in today's regime Bottineau and Kidman's histories would not have gone unnoticed.
The coroner's inquest was not looking to assign blame, but rather explore systemic issues surrounding Jeffrey's death.
The inquest was held more than a decade after Jeffrey's death because Bottineau only exhausted all of her appeals last year.