The 2003 death of Zachary Andrew Turner should have served as a cautionary tale for Manitoba's child and family services system.
The 13-month-old Newfoundland child died when his mother, Shirley Turner, clutched her son to her chest and jumped into Conception Bay, several kilometres outside of St. John's.
Peter Markesteyn says the same issues come up repeatedly in child-death cases.
Dr. Turner, a general practitioner, was facing extradition to the United States after her lover, Andrew Bagby, was found shot to death in Pennsylvania. Bagby was Zachary Turner's father.
Shortly before the murder-suicide, a judge cleared the way for Turner's extradition.
The circumstances leading up to the death of the child are detailed in a three-volume report compiled by Dr. Peter Markesteyn, once Manitoba's chief medical examiner and now a forensic consultant.
His report, issued last year, concluded the best interests of the children (Turner also had a 12-year-old daughter from a previous relationship) were not considered by that province's child welfare system.
On June 17, 2002, Zachary's grandparents, Kate and David Bagby, told the Newfoundland child authority they believed Turner had killed their son. They were concerned for the safety of their grandson.
He was killed a year later.
"The files are clear that Dr. Turner's stress levels were recognized as having the ability to compromise the care she provided for Zachary," Markesteyn wrote. "There is no suggestion that the Department had any concerns about the physical care Zachary received from his mother.
"What is much less clear is whether there was reason to be concerned about his mother's emotional and mental state; particularly in the months leading up to the extradition hearing and after the decision was made to extradite her."
It is Markesteyn's belief that the Newfoundland system did everything they could for Shirley Turner. They didn't do enough for her son.
"In this child welfare stuff, the primary concern, the child's interest has priority," he says during an interview in his Winnipeg office. In his career as a coroner, he has investigated the deaths of a number of children in care.
While he has no first-hand knowledge of Gage Guimond's murder, he feels the same issues come up time and time again.
"Was the best interest of the child looked after or the interests of other people?"
In Turner's death, Markesteyn concluded that there was no ongoing assessment of the safety needs of the children. He wonders how Gage Guimond's safety needs were monitored.
"My concern was, and that's just based on newspaper stories, was that this child may have been put into danger when he was moved to a culturally more appropriate setting. That could be, and I stress could be, what happened.
"One should not put a child at risk by putting it into an ethnically appropriate setting. You don't send a child to a dysfunctional home just because the people are Dutch or Indian or whatever."
If he were to conduct an investigation into Gage's death, Markesteyn says he'd be asking several pointed questions.
"Were the standards of the agency met? Did they see the child? Was the aunt a licensed foster parent? If she's not, you are now, for the sake of being culturally correct, endangering a child."
Markesteyn says the real tragedy is that the circumstances around Gage's death are nothing new.
"This is history repeating itself," he says.
He says there's no need for new laws or regulations concerning the work of child welfare workers.
"Just do what it says," he says emphatically. "It is critical that children are actually seen. Just do what the Act says you should do.
"Allow people doing to job the tools they need to do them. It may require more people, more training and education. There should be uniformity and standards.
"This is common sense. To apply to all the same standards is the greatest honor you can give to any minority. These children had no choice to where they were born or who their parents were."
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