TORONTO – The manipulative nature of a woman who ultimately starved her grandson to death only becomes clear with hindsight, and the workers who placed the boy and his siblings in her care shouldn’t be judged through that lens, lawyers suggested Wednesday.

Elva Bottineau kept Jeffrey Baldwin and one of his young siblings locked for long stretches of time in a cold, fetid room and chronically starved them, the coroner’s inquest into Jeffrey’s death has heard.

Jeffrey was a healthy baby when the Catholic Children’s Aid Society in Toronto placed him and a sister in the care of their grandparents, who by then were already looking after Jeffrey’s eldest sister.

But by the time he died at age five Jeffrey was so severely neglected and drastically wasted away that he weighed about the same as on his first birthday. He couldn’t lift his own head, the inquest heard.

It was only after Jeffrey’s death that the CCAS discovered in its own files that both Bottineau and husband Norman Kidman had previous convictions for child abuse.

No shortage of condemnation was hurled at Bottineau during the inquest’s closing submissions.

The lawyer for the York Region Children’s Aid Society referred to Bottineau as a “manipulating, soulless human being,” while gesturing at the screen on which Bottineau’s face appeared as she watched the inquest from prison. She is serving a life sentence for second-degree murder.

But to the workers who dealt with Bottineau as they put Jeffrey and his siblings in her care she appeared ever the caring grandma, lawyers for both the CCAS workers and the York CAS suggested.

“It was suggested it would have been obvious to ordinary people who exactly Ms. Bottineau was, but I suggest to you that’s hindsight,” lawyer Jordan Goldblatt told the jury.

At various times lawyers, health-care workers, neighbours, teachers, police officers and judges all came across Bottineau, and none contradicted the impression in the society’s files that she was the family’s pillar of strength, said Goldblatt, who represents the CCAS workers’ union.

“Ms. Bottineau was quite adept at fooling people and did so over a number of years,” he said in his closing submission.

The groups with standing at the inquest suggested dozens of recommendations the jury can make with an eye to preventing similar tragedies in the future. 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.

“It bears repeating that the most important part of the inquest is what is happening now,” said Maureen Currie, representing the York CAS. The agency was responsible for placing Jeffrey’s younger brother with the family, as his parents were living in that region when he was born.

The child should not have been placed in that home, Currie said, but what is important is to evaluate what the society knew then, which was largely based on information from the CCAS’s previous dealings with the family.

“In retrospect we know what a calculating, devious woman she was, but at the time she appeared to be doing the right things for what we now know were the wrong reasons,” Currie said.

The inquest has heard suggestions that Bottineau was interested in the monetary support she received for caring for Jeffrey and his siblings. But it appears from evidence heard at the inquest that the boy may have had developmental issues and Bottineau could not adequately handle them.

The coroner’s inquest is not looking to assign blame, but rather explore systemic issues surrounding Jeffrey’s death. The jury can make recommendations aimed at preventing such situations in the future.

The recommendations suggested to the jury include using Jeffrey’s story as a case study for training children’s aid workers, and implementing better information sharing across agencies involved with child protection.

Some of the groups have also suggested children’s aid workers be required to ask family members for identification. In various CCAS files Bottineau’s first and last names were spelled using many variations, from Alva to Eve and Buttineau to Battineau.