The jury at the Jeffrey Baldwin inquest pressed Friday for a full review of Ontario’s child protection standards, with a top recommendation being to merge the province’s children’s aid societies into one central agency.

That was one of 103 recommendations delivered on the final day of the coroner’s inquest into the circumstances that led to the 5-year-old being placed with his grandparents by the Catholic Children’s Aid Society. Neglected and abused, Jeffrey starved to death in 2002.

The inquest, which began last September, heard from 53 witnesses and viewed more than 300 exhibits. It was the culmination of an 11-year search for answers related to one of the most horrific cases of child abuse in recent memory.

Jeffrey’s short life was filled with horror. Sent to his grandparents’ east Toronto home along with his three siblings, to give his young and problematic parents a break, he and an older sister were locked inside a cold bedroom with no toys. They had little access to food, were forced to drink out of the toilet and to live in their own feces, and were beaten repeatedly.

Jeffrey weighed only 21 pounds when he died — less than he did on his first birthday. The once chubby-cheeked, smiling boy who loved Dinky cars and Superman had become a skeletal figure resembling a famine victim, or someone with full-blown AIDS, said the judge at his grandparents’ trial.

Elva Bottineau and Norman Kidman were convicted of second-degree murder in 2006 and sentenced to life in prison.

The CCAS has admitted it failed to perform record checks on Bottineau and Kidman, who had prior convictions for assault on their own children.

On Friday, Bottineau, watching via video from prison, listened along with the other parties as the jury presented sweeping but non-binding recommendations directed at institutions including the CCAS, government ministries, the Toronto District School Board, and Toronto police.

The four jurors want the Ministry of Children and Youth Services to conduct a feasibility study exploring amalgamating local children’s aid societies. The jury said “the amalgamated children’s aid society must be sensitive to the cultural and religious differences of the families they serve, while recognizing that the safety of the province’s children is paramount.”

The jury also wants the province’s information-sharing database for children’s aid societies, known as CPIN, to be fully operational within two years. And it said the ministry should fund a review of all child-protection standards.

Children and Youth Services Minister Teresa Piruzza told the Star on Friday afternoon that she hadn’t yet read the recommendations, but she and her staff would be taking a close look to determine what measures could be adopted.

“We know there is more we can do,” she said.

She defended her ministry’s decision not to seek standing at the inquest — Piruzza herself never attended — by saying it felt the parties were well positioned to work out the issues, adding the ministry had representatives in the audience each day.

Other inquest recommendations include:

Co-teaming for child-protection workers in situations where the worker’s safety is threatened, and annual follow-up visits.

A provincially funded public awareness campaign about spotting and reporting child abuse, including a 1-800 number to facilitate reporting.

An authorization process for all new child-protection workers.

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<bullet>Penalties for individuals who fail to report child abuse and neglect.

<bullet>A case study, developed by the CCAS for training purposes, based on Jeffrey Baldwin’s case to be used across the province.

Other recommendations target the Ministry of Education, asking it to address child abuse and neglect in the curriculum for students from kindergarten to Grade 12. Their final recommendation is for the coroner to hold a news conference one year after all institutions have received the recommendations, to give an update on their implementation.

All parties expressed satisfaction with the inquest’s outcome.

“I think that this jury’s recommendations will help ensure that no other child suffers and dies like Jeffrey did,” said Jeffrey’s siblings’ lawyer, Freya Kristjanson, appearing at times emotional.

Irwin Elman, the provincial advocate for children and youth, said that although he was pleased, he is still urging the premier to call a public inquiry into the protection of children.

The Catholic Children’s Aid Society will be taking a hard look at all recommendations, said its executive director, Mary McConville.

“The biggest lesson learned (for CCAS) is that we should have known who Elva Bottineau and Norm Kidman were,” she said. “They seemed to be well-meaning. Elva Bottineau really became, literally, an ally of the society. And we didn’t check her out. We didn’t check Norm Kidman out.”

The jury also asked the City of Toronto or another level of government to honour Jeffrey Baldwin’s memory with a permanent memorial.

There is currently a small memorial to Jeffrey in Toronto’s Greenwood Park, near where he lived with his grandparents. The memorial is composed of a tree and a bench with a plaque bearing Jeffrey’s image.

There are plans to add a second memorial, a statue of Jeffrey dressed as his favourite superhero, Superman, this fall.