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

Just Posted

(Facebook/Kelowna Cabs)
Kelowna Cabs reaches tentative agreement with dispatchers union

The tentative agreement could help end the dispute between the taxi company and the dispatchers

sdaf
Lake Country home destroyed in large blaze, 11 dogs rescued

Fire crews are responding to 10839 Hallam Drive

Festivals Kelowna president Richard Groves and executive director Renata Mills wrap themselves in the flag during the announcement of preparations for the 2018 Canada Day festival. (Alistair Waters/Capital News)
Festivals Kelowna cancels Canada Day celebrations for second year in a row

The group cited logistic issues in their announcement

Central Okanagan Public Schools is assisting with the distribution of a donation of $500 to every Grade 12 graduating student in the school district. (File photo)
Central Okanagan Grade 12 grads get $500 surprise

Anonymous donor gifts $500 to every Grade 12 student

A vehicle was fully engulfed in flames before around 11:10 p.m. Wednesday, June 16, 2021. (Kerry Hutter - contributed)
UPDATE: Kelowna man cuffed after carjacking in Vernon

Crime spree: Man robs couple at Coldstream lookout at gunpoint, sets a vehicle ablaze

Bear wanders Kelowna on June 15. (Michelle Wallace/Facebook)
Bear climbs fence, uses crosswalk in Kelowna

The bear was spotted on Baron Road Wednesday evening

Jeanette Megens
KCR: Volunteering is sharing your story

Kelowna Community Resources shares stories of its volunteers in a weekly column

This photo of the small wildfire burning above Naramata was taken at 8 p.m. on Thursday, June 17, 2021 (Monique Tamminga Western News)
BC Wildfire on scene of small wildfire above Naramata

Smoke has been showing since earlier in the day

Students in the Grade 10 entrepreneurship program at Summerland Unisus School have completed a cookbook with international recipes. (Contributed)
Summerland students create virtual international cookbook

Entrepreneurship program at Summerland Unisus School uses virtual cookbook as fundraiser

Cannabis bought in British Columbia (Ashley Wadhwani/Black Press Media)
Is it time to start thinking about greener ways to package cannabis?

Packaging suppliers are still figuring eco-friendly and affordable packaging options that fit the mandates of Cannabis Regulations

Hundreds of people, young and old, joined the three-day Walking Our Spirits Home procession, honouring residential school survivors, those who never made it home and all those affected by the institutions. Here people walk the third portion on June 13. (Martha Wickett - Salmon Arm Observer)
Walking Our Spirits Home from Kamloops provides path to healing

First Nations in and beyond Secwépemc territory join in to honour residential school survivors

FILE – A science class at L.A. Matheson Secondary in Surrey, B.C. on March 12, 2021. (Lauren Collins/Surrey Now Leader)
Teachers’ union wants more COVID transmission data as B.C. prepares for back-to-school

BCTF says that details will be important as province works on plan for September

201 First Street West 1980s. Prior revitalization. (Photo from Revelstoke Museum and Archives)
Man who redesigned downtown Revelstoke honoured with lifetime achievement award

Robert Inwood has worked on historical projects across the province

Provincial health officer Dr. Bonnie Henry outlines B.C.’s COVID-19 restart plan, May 25, 2021, including larger gatherings and a possible easing of mandatory masks on July 1. (B.C. government photo)
B.C. records 120 new COVID-19 cases, second vaccines accelerating

Lower Pfizer deliveries for early July, Moderna shipments up

Most Read