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TORONTO – Seven years after Katelynn Sampson’s small, battered body was discovered in a Toronto apartment, a coroner’s inquest will investigate just what allowed the little girl to be beaten to death by her legal guardians.

The circumstances surrounding the seven-year-old’s 2008 death drew public outrage and raised questions about how she appeared to have been failed by several agencies who ought to have protected her.

Some hope the inquest beginning Monday will finally address the cracks Katelynn appeared to have fallen through.

“We still have that question – how could this have happened,” said Irwin Elman, Ontario’s advocate for children and youth, who has long called for the inquest into Katelynn’s death and has standing at the proceeding.

“I think the inquest, in my mind, gives us a chance as an entire province to have a conversation about how this happened, how we can prevent it from happening again and even, in a sense, have this inquest be the first sentence in a larger conversation about how we protect children and support families.”

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Elman attended Katelynn’s funeral and still has a copy of the event’s program hanging in a frame above his desk to remind himself, he said, about the need to do better for vulnerable children

“I think we will uncover, at the very least, that there is disarray in the child welfare system. While things may seem to have changed, they haven’t changed.” Tweet This

A jury at the inquest will examine the events around Katelynn’s death and may issue recommendations on how to prevent similar cases. The proceeding is expected to take four weeks and will hear from about 30 witnesses.

Katelynn came to be cared for by her guardians after her mother, Bernice Sampson, who was addicted to crack cocaine, decided to try giving her a better life.

Sampson entrusted her friends, Donna Irving and her boyfriend Warren Johnson, with Katelynn’s care, hoping her daughter would be in good hands.

It was later revealed, however, that a judge granted custody of Katelynn to Irving despite the woman’s criminal convictions for prostitution, drugs and violence. Court transcripts revealed few questions were asked about Irving’s record.

READ MORE: Ontario’s children and youth advocate wants more powers

Irving and Johnson also called the Children’s Aid Society at one point, saying they no longer wanted the child, but their call was transferred to Native Child and Family Services because Katelynn was half-Anishinabe.

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It took a case worker 16 days to contact Irving, but by then she said she was getting help from Katelynn’s school, which wasn’t true.

In August 2008, Irving called 911 and claimed the little girl had stopped breathing while choking on food.

She was arrested after emergency personnel arrived to find signs of obvious trauma on Katelynn’s body that contradicted Irving’s story.

It was revealed that Katelynn had slept on a bedroom floor, missed school a number of times and suffered prolonged physical abuse at the hands of her guardians.

She was found with 70 injuries on her body after she went into septic shock. One police officer said her injuries were the worst thing he had seen in 20 years of policing.

Irving and Johnson pleaded guilty to second-degree murder in Katelynn’s death and were sentenced in 2012 to life in prison with no chance of parole for 15 years.

At the time, the judge who delivered their sentence said of the case that “alarm bells were ringing and no one was responding.”

In the aftermath of Katelynn’s death, the provincial government made changes requiring guardians applying for custody who are not parents to provide a police background check as part of their application.

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