The prolonged abuse and eventual murder of a seven-year-old girl by her court-appointed caregiver is raising questions about oversight practices at child welfare agencies in Toronto.
In August 2008, Katelynn Sampson, 7, died after being abused for months at the hands of her caregivers Donna Irving and Warren Johnson.
Both Irving and Johnson pleaded guilty to the second-degree murder of the little girl on Tuesday.
The court heard that Katelynn was abused daily before her eventual death from septic shock, which was caused by her untreated wounds.
Court also heard that when Katelynn's principal reported her suspected abuse to the Children's Aid Society of Toronto, that agency faxed Katelynn's file to Native Child and Family Services, an agency which said it never got the file.
But Sampson's death certainly wasn't the first one where a child under the supervision of a child welfare organization has died in care.
A major problem, said Ontario Ombudsman Andre Martin, is that the Children's Aid Society lacks an independent oversight body.
The Children's Aid Society says it has made changes in the wake of Katelynn's death, but there is no way to tell how these changes are working.
"This office has been calling for the oversight of CAS since 1975, successive ombudsmen have raised the issue, so it's not new," said Marin.
Ontario remains the only province in Canada that prevents its ombudsman from investigating the child welfare system, something Marin has repeatedly pointed out as an area that needs to change.
Privacy regulations also prevent the media from reporting whether or not a murdered child had contact with a child welfare agency, unless that information comes out in court, as was the case with Katelynn.
Unfortunately, Katelynn's death isn't the first time a Toronto child has died while their case was before a child welfare agency.
In 1998, Randal Dooley, 7, was routinely abused and was eventually killed by his father and stepmother.
His death came after school staff told child welfare agencies about suspected abuse.
In 2002, Jeffrey Baldwin, 5, starved to death while in the care of his grandparents, who were his court-appointed caregivers while Catholic Children's Aid Society investigated allegations against Jeffrey's parents.
His grandparents were convicted of second-degree murder in 2006.
After Jeffrey's death, retired homicide detective Mike Davis called for an inquest.
"This is something only a public inquiry can look into and look into the systemic issues that are underlying with the Catholic Children's Aid Society," he told reporters back in 2006.
Davis finally got his wish. An inquest into Jeffrey's death was called in 2011, 10 years after his murder. A date for that inquest has not yet been set.
There was no inquest into Randal's death.
There is still no word on whether there will be an inquest into Katelynn Sampson's murder.
With files from CTV Toronto's Tamara Cherry
