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

5 to 10 cm of snow still coming to Fraser Valley: Environment Canada

Hard to say when the freezing rain will turn to regular rainfall, Environment Canada says

Slideshow: Hope’s winter weather in photos

Readers submit photos of Hope under a blanket of snow

RCMP looking for tips in rash of crime in Hope

Theives broke into homes and cars in the Kawkawa Lake area

Fraser Cascade superintendent announces retirement

Dr. Karen Nelson has worked for School District 78 for 29 years

FVRD seeking outdoor rec feedback

Open house meetings slated for next week

‘Like an ATM’: World’s first biometric opioid-dispensing machine launches in B.C.

First-of-its-kind dispensing machine unveiled in the Downtown Eastside with hopes of curbing overdose deaths

Canucks extend home win streak to 8 with 4-1 triumph over Sharks

Victory lifts Vancouver into top spot in NHL’s Pacific Division

BC Green Party leader visits northern B.C. pipeline protest site

Adam Olsen calls for better relationship between Canada, British Columbia and First Nations

B.C. society calls out conservation officer after dropping off bear cub covered in ice

Ice can be seen in video matted into emaciated bear cub’s fur

Horgan cancels event in northern B.C. due to security concerns, says Fraser Lake mayor

The premier will still be visiting the city, but the location and day will not be made public

B.C. landlord sentenced to two years in jail for torching his own rental property

Wei Li was convicted of intentionally lighting his rental property on fire in October 2017

VIDEO: Highway 1 left looking like winter war zone with dozens of stranded vehicles

Tow-truck driver says 30 vehicles still dot snowy landscape, including one rolled-over dairy truck

PHOTOS: Eastern Newfoundland reeling, search underway for missing man after blizzard

More than 70 centimetres of new snow fell overnight, creating whiteout conditions

Prince Harry, Meghan to give up ‘royal highness’ titles

‘Harry, Meghan and Archie will always be much loved members of my family,’ says Queen Elizabeth II

Most Read