TORONTO -- A seven-year-old Toronto girl was overlooked and ignored by those who had the duty to save her and died as a result of their "significantly flawed decision making," a coroner's inquest heard Friday.

Despite gaps in their files, child protection workers at two agencies had all the information they needed to rescue Katelynn Sampson from her abusive guardians, the lawyer representing her mother said.

Officials at the girl's school also knew enough to intervene, given Katelynn's noticeable injuries and prolonged absences, Suzan Fraser said.

Though they called child welfare authorities five times, "they could have done more," she said.

And at no point did anyone ask Katelynn how she was doing or what she wanted, Fraser said in her closing submissions to the jury.

"Her death was not inevitable ... there were opportunities to alter the course of her life, to see her, to speak with her," she said. "Katelynn did not have to die."

The coroner's counsel said in her submissions that Katelynn was "unseen and unheard" by those whose job it was to ensure her safety.

"So many agencies and institutions circled around her and yet remained peripheral while Katelynn was a ghost at the centre," Nicole Bailey said.

"It should have been simple -- Katelynn should have been the focus, the heart."

After hearing from 37 witnesses over four months, jurors on Friday received a series of proposed recommendations from lawyers in the case, including more than 30 supported by all parties. The jury may accept, change or reject them in issuing its own report at the end of the inquest.

One proposal involved the creation of Katelynn's Principle, a doctrine meant to ensure children are "at the centre" of the child welfare system.

Another would see all four Toronto child welfare agencies adopt a shared intake service with a single phone number and location.

The sharing of information between the city's four overlapping child welfare agencies has been a recurring theme at the inquest, but Fraser said they simply didn't use the knowledge they had, with tragic results.

Katelynn Sampson was beaten for months while in the care of Donna Irving and Warren Johnson, once so hard that her liver ruptured, the inquest has heard.

Her battered body was found early on Aug. 3, 2008, in the couple's apartment. Irving and Johnson later pleaded guilty to second-degree murder in her death and were sentenced to life in prison with no chance of parole for 15 years.

Katelynn's mother, Bernice Sampson, was addicted to crack and gave her daughter to Johnson and Irving in a misguided attempt to give Katelynn a better life.

Both the Children's Aid Society and Native Child and Family Services were contacted about Katelynn or the couple while she was living with them. Oversight was transferred to the latter agency because of Irving's aboriginal heritage.

The inquest has heard that one caseworker made several attempts to have the agency investigate after finding Katelynn in the home. But Irving's file was quickly closed after she lied and said Katelynn had gone back to live with her mother.

Months later, Irving called the Children's Aid Society saying she no longer wanted the child. The call was transferred to Native Child and Family Services.

It took a case worker 16 days to contact Irving, but by then she said she was getting help from Katelynn's school, which wasn't true.

The Children's Aid Society also raised concerns after a record check found allegations of sexual abuse against Johnson, though no charges were laid. Another call about Katelynn came in to the Children's Aid Society about a month later but the record got lost and it was never addressed.

Anyone who visited Irving and Johnson's home would have known that Katelynn should not be in their care, Irving's lawyer said in her closing statement.

And every child protection worker, every school official, and every police officer who interacted with the girl or her guardians "should have seen the red flags," Julie Kirkpatrick said.

"There were so many opportunities for Katelynn to be saved by so many people."