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

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

BREAKING: Interior Health to add 495 long-term seniors care beds

Nelson, Kelowna, Kamloops and Penticton to receive new facilities

Lost Langley couple rescued from James Lake, near Kelowna

The rescue occurred Saturday, July 11

QUIZ: Are you ready for a summer road trip?

How much do you really know about roads, motor vehicles and car culture? Take this quiz to find out.

Provincial COVID-19 data can now be used for B.C. to prepare for a second wave

In the past week, B.C. has seen a slight spike in daily test-positive case counts

Wage subsidy will be extended until December amid post-COVID reopening: Trudeau

Trudeau said the extension will ‘give greater certainty and support to businesses’

Drive-by shooting in Kamloops

This is the second drive-by shooting in the city in the last two weeks

Revelstoke RCMP searching Columbia River for possible body

Boats and aircrafts are searching the area

Tree planters get help with COVID-19 protective measures

Ottawa funds extra transportation, sanitizing for crews

Vernon Mounties share video of cyclist hit by vehicle, assaulted

Police release short video clip of cyclist struck by SUV in March 2020, and photos of suspects

Missing woman last seen in Lumby

Vernon North Okanagan RCMP seek public’s help in locating 32-year-old woman

Trudeau apologizes for not recusing himself from WE decision

He says his and his family’s longtime involvement with the WE organization should have kept him out of the discussions

Interior Health identifies more locations with COVID-19 exposure in Kelowna

Anyone who participated in events in the Kelowna downtown and waterfront area between June 25 and July 6 should monitor closely for symptoms

Most Read