09/09/2013 04:00 EDT | Updated 11/08/2013 05:12 EST

First responder still disturbed by 'soul-destroying' sight of starved boy

TORONTO - The first emergency crews to find the body of a boy so skeletal he looked like a starving third-world child are still deeply disturbed by the "soul-destroying" sight more than 10 years later, a coroner's inquest heard Monday.

But the boy's grandmother, his primary caregiver, who had summoned them to the home with a nonchalant 911 call that morning treated his death as an annoyance, a pair of first responders told the inquest into Jeffrey Baldwin's death.

Four years after his grandparents got custody of Jeffrey and his three siblings, he died of bacterial bronchopneumonia as a complication of chronic starvation. A few weeks shy of his sixth birthday when he died, Jeffrey weighed 21 pounds — about the same as he did on his first birthday.

What paramedic Marc Dugas saw the morning of Nov. 30, 2002, was horrifying.

"You see something like that and it's just soul destroying," he said, sitting in front of a photo that was taken in the ambulance of Jeffrey's emaciated body.

"It was the complete and utter destruction of dignity to any child or human being, in my opinion."

Jeffrey had almost no fat or muscle mass, Dugas said. His abdomen was swollen. His limbs were wasted. He had sores all over his little body. He looked like a starving child from Africa, Dugas said.

Usually Dugas said he is able to "switch off" and not take the disturbing images from his work home with him, but it was different with Jeffrey.

"It got so I couldn't sleep at night," he said. "Every time I closed my eyes I would see it for days afterwards. Very rarely in the 18 years I've been in service has that happened."

Elva Bottineau and Norman Kidman have already been convicted of second-degree murder in Jeffrey's death. The coroner's inquest is exploring systemic issues surrounding Jeffrey's death, rather than looking to assign blame.

Bottineau and Kidman were granted custody of Jeffrey and his three siblings without so much as a background check. Both had a previous child abuse conviction — a fact that neither the Catholic Children's Aid Society nor the York Children's Aid Society realized until after Jeffrey died.

"After the grandparents were granted custody of each child by the court, the children's aid society closed their file and no worker oversaw or checked in on the family," said coroner's counsel Jill Witkin.

"Moreover, no worker performed any background checks on Elva and Norman prior to the transfer of a child, no criminal record checks and no internal checks of past society files. Had proper checks been done, they would have revealed a horrific history of incapable parenting and child abuse."

Dugas was shocked by Jeffrey's condition, but the rest of the family — six adults and six children were living in the house, the inquest has heard — seemed unconcerned, he said. When paramedics worked on Jeffrey in the back of the ambulance, no one came out of the house to inquire about him, Dugas said.

Even when the first emergency crew arrived on scene, they had to knock to get Bottineau to come to the door, and she seemed annoyed at the sound, said Toronto Fire Capt. Royal Bradley.

"She told me to keep it down because there was a child just inside, sleeping on the couch," Bradley testified.

It seemed to him that "something's really, desperately wrong" in that house, he said.

"Where was the emotion?" Bradley said. "There wasn't one damn tear shed."

The inquest heard an audio recording of the 911 call Bottineau placed that morning, on which she said Jeffrey had recently stopped eating and drinking and he "might have a touch of the flu."

"Apparently my grandson is not breathing right now," she says. She asks for a police car to be sent, but dispatch tells her she needs an ambulance.

The call ends as paramedics arrive and one can be heard in the background asking, "What's the history, folks?"

"His history's fine," Bottineau responds.

Bottineau told Bradley that Jeffrey had just seen a doctor two weeks ago and he had been fine, Bradley said. But he didn't buy it.

In fact, the inquest heard, Jeffrey hadn't been to the doctor since he was 17 months old. He wasn't enrolled in school and neighbours never saw him outside, said Witkin.

"It doesn't appear that he was ever even taken out of the house," Witkin told the jury. "Rather, the evidence shows him to have been a hidden, neglected and malnourished child, who ultimately succumbed to his maltreatment."

Jeffrey and one of his sisters were frequently locked in their cold, barren bedroom, soaked with urine and stained with feces, the inquest heard.

Major changes have been implemented at the CCAS and children's aid societies across Ontario since Jeffrey's death, including increased family history, background and record checks. Relatives who become caregivers are also subjected to the same rigorous standards as foster parents and adoptive parents.