There were many missed opportunities.

To save the lives of Jared and Andrew Osidacz.

To save the lives of others who come after them.

Just as there were lost chances to intervene between the boy and the violent father who killed him, the very inquest into their deaths has become another missed opportunity.

To learn the whole truth. To explore the issues. To find answers.

And, ultimately, to prevent other similar deaths.

Jared was eight when he was stabbed to death by his father while on an unsupervised court-ordered visit. Unsupervised, despite Andrew's past conviction for a violent assault against Jared's mother. That final night Andrew also repeatedly stabbed his girlfriend, her eight-year-old daughter and then held Jared's mom, Julie Craven, at knifepoint. Andrew's rampage ended when he was fatally shot by Brantford police.

On Thursday, the three women and two men of the jury for the coroner's inquest into Jared and Andrew's homicides brought forward 35 recommendations to prevent the same thing happening again.

While a handful of the recommendations are worthwhile, the majority are of the boilerplate sort that crop up at every inquest held across the province: more funding for programs; better education for workers in the field; improved communication between agencies and ministries.

Most of the recommendations (which are all non-binding) were handed to the jury by the lawyers who spent the four weeks of the inquest protecting their clients -- the Children's Aid Society, the Ministry of the Attorney General, the Ministry of Community Safety and Correctional Services -- from lawsuits. Hence the complete absence of specific local agency names in any of the recommendations.

And therein lies the problem with this miserable failure of an inquest.

From the beginning it was set up to fail because it was not allowed to seek the full truth. Dr. James Edwards, the presiding coroner, set a scope for the proceedings which myopically focused on the hours and days leading up to the deaths, all but turning a blind eye to years of domestic violence, criminal and family court decisions and probation orders.

Jared's death was a domestic homicide. Plain and simple. Yet, the inquest did not treat it as such.

The irony here is that an inquest cannot find criminal wrongdoing, nor can it lead to financial compensation. In other words, an inquest should be the one forum where all parties can be open and honest without fear of repercussions. And yet, in reality, most of the parties are too fearful for their reputations and pocketbooks to be forthcoming.

An inquest should be able to find out what mistakes were made and by whom. But at this inquest, at the direction of Dr. Edwards, extraordinary steps were taken to keep names and other specifics out of it in favour of talking in useless generalities about ministry policies and procedures.

It is as though the coroner didn't want to hold anyone accountable. Or even make anyone uncomfortable.

Well, a boy is dead, damn it. And his father killed him.

Too bad if that makes people squeamish. Or if some social worker or probation officer has to be called to account. If an inquest is to have any sort of chance whatsoever of making a real difference in the future, a good strong light has to shine into every corner.

Years ago, coroner's inquests in our community had an impact. They dug up the details of deaths in a thorough manner and the recommendations that resulted were pointed and meaningful. Think of the inquest into the suicide of murderer Jonathan Yeo. It changed the way police services work together, the way border agencies do their jobs and the way wanted offenders are supposed to be handled. Or the inquest into the murder of two-year-old Zachary Antidormi, which brought about changes to our mental health system and its relationship with the police.

Lately, inquests have become public relations exercises instead of fact-finding missions.

A recent inquest in Kitchener into the police shooting of a former Hamilton man shares many of the same problems as the Osidacz inquest.

Trevor Graham was killed by police during a drug story robbery. Trevor, 26, had mental health and addiction issues. The road that led him to be at the pharmacy that night was long. And yet, the scope of the inquest focused primarily on the fatal shooting, rather than issues of the justice or health system.

Both inquests were mandatory because they involved deaths in police custody.

Both cost the taxpayers a great deal of money.

But unless inquests -- and the coroners who preside over them -- are serious about gathering the evidence a jury needs to make well-informed and necessary recommendations, really, what is the point?

Susan Clairmont's commentary appears regularly in The Spectator. sclairmont@thespec.com 905-526-3539

Best of the recommendations

* Ministry of Children and Youth Services (MCYS), Ministry of the Attorney General (MAG) and Office of the Children's Lawyer -- After a vicious assault and charges laid, the accused is put on bail with supervised access to children until the courts decide appropriate intervention.

* MAG -- Persons identified as at risk for lethality should be re-evaluated on an ongoing basis including, but not limited to, termination from, or completion of an intervention program. Copies of such evaluations be provided to other justice partners, including probation and parole and the CAS, where there are children involved or children in the home of the primary/joint or access parent.

* Ministry of Community Safety and Correctional Services (MCSCS) -- All Ontario probation offices should form high-risk teams with other partners in the community such as police, the Crown's office, women's shelters and the CAS to case manage high-risk domestic violence cases, particularly those where the offender has been identified as being at high risk for lethality. That such high-risk teams partner with mental health professionals in appropriate cases.

* MCSCS -- Probation officers and supervisors should be directed that an anger management program is not a substitute for a domestic violence rehabilitation program.

* Ontario Association of Children's Aid Societies -- Should fundamentally alter its strategy for assessing risk in cases involving domestic violence so the weight of decision-making rests on risk of harm posed by the perpetrator as well as the capacity of the non-offending parent to take protective action.

For the complete list of recommendations, visit thespec.com.