Systemic failures in long-term care allowed Ontario nurse to kill 8 patients: inquiry

Elizabeth Wettlaufer has been referred to as Canada’s first-known “health-care serial killer

Elizabeth Wettlaufer is escorted by police from the courthouse in Woodstock, Ont., on June 26, 2017. THE CANADIAN PRESS/Dave Chidley

Elizabeth Wettlaufer is escorted by police from the courthouse in Woodstock, Ont., on June 26, 2017. THE CANADIAN PRESS/Dave Chidley

Systemic failures in long-term care allowed Canada’s “first known health-care serial killer” to murder eight elderly patients without raising suspicion, a public inquiry said Wednesday, calling for fundamental changes to prevent such tragedies in the future.

In a report capping a two-year probe of nurse Elizabeth Wettlaufer’s case, the Ontario inquiry said those failures stem in part from a lack of awareness on the risk of staff members deliberately hurting patients.

READ MORE: Two bodies exhumed in probe into former Ontario nurse charged with murder

“It appears that no one in the long-term care system conceived of the possibility that a health-care provider might intentionally harm those within their care and, consequently, no one looked for this or took steps to guard against it,” commissioner Eileen Gillese said in releasing the four-volume document.

“Fundamental changes must be made — changes that are directed at preventing, deterring, and detecting wrongdoing of the sort that Wettlaufer committed.”

Wettlaufer is serving a life sentence after pleading guilty in 2017 to killing eight patients with insulin overdoses and attempting to kill four others. She was arrested after confessing to mental health workers and police. She has said she chose insulin for her crimes because it wasn’t tracked where she worked.

The commission’s report lays out 91 recommendations directed at the provincial government, long-term care facilities and nursing regulators, including measures to raise awareness of serial killers in health care and make it harder for staff to divert medication.

It calls on the province to launch a three-year program allowing each of Ontario’s more than 600 long-term care facilities to apply for a grant of $50,000 to $200,000 to increase visibility around medication, and use technology to improve tracking of drugs.

The money could be used to install glass doors or windows in rooms where medication is stored, to set up security cameras in those rooms, to purchase a barcode-assisted medication administration system or to hire a pharmacist or pharmacy technician, among other measures, the report said.

To ensure proper staffing levels in homes, the province should conduct a study to determine how many registered employees are required on each shift, and table a report by July 31, 2020, the commission said. If the study finds more staff are needed, the government should provide homes with more funding, it said.

Meanwhile, Ontario’s chief coroner and forensic pathology service should conduct more investigations into deaths of patients in long-term care, informed by a document submitted by homes after a resident dies, the report said. The form itself should be redesigned to hold more information and be submitted electronically so unusual trends can be spotted.

RELATED: Ex-nurse accused of killing 8 seniors was once fired over medication errors, docs show

Relatives of some of Wettlaufer’s victims said they welcomed the recommendations but stressed action is needed to restore trust in long-term care.

“My dad was murdered and many other people’s family (members) were murdered and if the government … doesn’t do anything, more of our family members will be murdered,” said Susan Horvath, whose father Arpad Horvath was killed by Wettlaufer in 2014.

The province said Wednesday that it would review the report, determine next steps in the coming weeks, and provide a full accounting of its progress in a year.

Paola Loriggio , The Canadian Press

Like us on Facebook and follow us on Twitter

Get local stories you won't find anywhere else right to your inbox.
Sign up here

Just Posted

(Photo submitted)
Ermineskin citizen graduates vet school, is part of busy practice

Dr. Justin Hodgson is rolling up his sleeves in Meadow Lake, Sask.

Shaela Dansereau/Pipestone Flyer
Wetaskiwin City services impacted by new public health measures

Public centers and availability to public impacted by the new public health measures.

Wetaskiwin Composite High School. Shaela Dansereau/ Pipestone Flyer.
Wetaskiwin Regional Public Schools prepare for transition back to online learning

Grades 7-12 will are mandated to transfer to online learning starting Nov. 30, 2020.

Alberta’s chief medical officer of health, Dr. Deena Hinshaw, said growing COVID-19 case numbers continue to be a concern in the province. (Chris Schwarz/Government of Alberta)
Alberta announces 1,077 new COVID-19 cases Thursday

There are currently 14,052 active cases in the province

A person enters a building as snow falls in Ottawa, Sunday, Nov. 22, 2020. Ottawa has been successful in limiting the spread of COVID-19 during its second wave thanks to the city’s residents who have been wearing masks and staying home, said Ottawa’s medical officer of health Dr. Vera Etches. THE CANADIAN PRESS/Justin Tang
People to thank for Ottawa’s success with curbing COVID-19: health officer

The city’s chief medical officer said much of the credit goes to the people who live in Ottawa

Ridge Meadows RCMP are developing a new strategic plan for the detachment. (Phil McLachlan)
UPDATED: Male wanted for Montana First Nation shooting arrested

Darcy Cattleman located in Conklin, Alta.

The Red Deer Games Foundation has made changes to its grant program as a result of the ongoing COVID-19 pandemic. (Photo supplied)
Red Deer Games Foundation adjusts grant program due to COVID-19 pandemic

The foundation postponed the spring 2020 grant program due to the COVID-19 pandemic

Alexandre Bissonnette, who pleaded guilty to a mass shooting at a Quebec City mosque, arrives at the courthouse in Quebec City on February 21, 2017. THE CANADIAN PRESS/Mathieu Belanger - POOL
Court strikes down consecutive life sentences; mosque shooter has prison term cut

The decision was appealed by both the defence and the Crown

Gold medallists in the ice dance, free dance figure skating Tessa Virtue and Scott Moir, of Canada, pose during their medals ceremony at the 2018 Winter Olympics in Pyeongchang, South Korea, Tuesday, Feb. 20, 2018. THE CANADIAN PRESS/AP-Charlie Riedel
Olympic champions Virtue, Moir and Tewksbury among 114 Order of Canada inductees

Moir and Virtue catapulted to national stardom with their gold-medal performances at the Winter Olympics in 2018

Shoppers line up in front of a shop on Montreal’s Saint-Catherine Street in search of Black Friday deals in Montreal, Friday, Nov. 27, 2020. THE CANADIAN PRESS/Paul Chiasson
Black Friday shopping in a pandemic: COVID-19 closes some stores, sales move online

Eric Morris, head of retail at Google Canada, says e-commerce in Canada has doubled during the pandemic.

skip2
Rimbey Christian School students experience the joy of giving

Grades three and four students raised $2,000 for Somalian children

Most Read