She was denied the use of a toilet and rarely bathed or fed.
The toddler, who was born in British Columbia, was supposed to be cared for by her maternal grandfather, who had been given custody after the child was taken from her drug-addicted mother. But instead, children's advocates say the girl was lost in a child welfare system that failed her.
Mary Ellen Turpel-Lafond, B.C.'s Representative for Children and Youth, says there is not enough oversight of children in care who move between provinces.
"We have inter-provincial regulation of eggs, chickens, cars, tractors and so forth, but we don't seem to have anything going with respect to children to the level of concern that we should have," Turpel-Lafond said in an interview with The Canadian Press.
For example, Turpel-Lafond said no province could even give her the number of the children received from or sent to other jurisdictions, or say if there was follow-up on the kids once they moved.
An inter-provincial protocol has existed since 2001, but Quebec has never signed it.
"It's more of a protocol about who has to foot the bill," said Turpel-Lafond.
"When we look at how do you decide where to send (the children), what's the follow up, what's the support, we actually then enter a very big safety gap. There's a protocol, nobody understands it, nobody follows it, nobody tracks the numbers in and out of provinces across Canada."
Cheryl Milne, chairwoman of the Canadian Coalition for the Rights of Children, said because movement between provinces is not that frequent, it's not necessarily the top priority on each province's radar.
Part of the problem is that standards, such as the method of monitoring, are different for each province.
"What we are seeing in these rare, but tragic cases is that that's where the gaps are discovered and they're discovered when a child is badly mistreated or dies," said Milne.
"It would help to have everybody on the same page so that the expectations of the receiving agency, for example, who may have to monitor because the child is now in their jurisdiction...then at least there is some understanding about what is expected."
Milne said no one is taking the lead.
"The problem is that there doesn't seem to be any really good incentives for the provinces to work together," she said.
"There aren't resources really put toward that and there is no leadership coming from the federal government in that regard."
She said there is money for research, such as a national incidence study for child abuse and neglect, but no funds for keeping track of children in care.
The principle investigator for that research study said one of the challenges is that there is no national number for how many children are in care, period.
Nico Trocme, professor of social work at McGill University, said the well-being of children in Canada should be a national priority and the lack of basic information is a problem. But he's not surprised that no one can say how many kids in care are moving between provinces.
"The reason that's not being tracked is because many other things are not tracked," said Trocme.
"But the advocate is quite correct in saying ... for those children who end up being placed across jurisdictions, there should be some sense of tracking and standards."
Caring for children falls under provincial jurisdiction, but Trocme said reporting on their well-being should also be a national priority.
"I think it's outrageous that we don't have a national strategy with respect to children in out-of-home care, that we don't have national statistics on how these children are doing."
Saskatchewan's children's advocate said both provinces involved in a child's move are supposed to negotiate agreements on what services will be provided in each case.
But Bob Pringle said the Saskatchewan government can't tell his office how many agreements it has.
"We've seen some of these agreements and some are really good and some are very poor," said Pringle.
"We're concerned that this is really hit and miss and this is how children get lost. The case (of the toddler) should have been tickety-boo smooth, it should have gone smoothly. But there were all kinds of missed opportunities and red flags that were ignored."
Turpel-Lafond addressed those red flags in a scathing report entitled "Out of Sight: How one aboriginal child's best interests were lost between two provinces."
The report, released last Tuesday, focused on the toddler who was given to her grandfather — a drug addicted, abusive man with 70 criminal convictions.
The report said the children's ministry in B.C. relied on an inadequate report on the grandfather's criminal record and parenting background when it decided to allow the little girl to be sent to Saskatchewan. The ministry also didn't do any planning to address her post-placement safety or needs.
Saskatchewan agencies were criticized for refusing to do any follow-up. Workers with a First Nations child services agency made a couple of home visits, but never laid eyes on the girl.
She endured 18 months of abuse and neglect before she was taken from her grandfather.
Turpel-Lafond's report recommended protocols be revised to include national standards for placements and a national strategy to monitor, track and report on the well-being of children in those placements.
"You don't just find a relative and dump a child and then later on say, 'Oh, that was unfortunate, I guess maybe there should be a criminal prosecution,' " said Turpel-Lafond.