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

MLAs say Parksville will better prepared for flooding emergencies

RDN receives $150K in funding for Englishman River Flood Hazard Mapping project

Campaign aims to raise $50K for young family of deceased Vancouver Island skydiver

James Smith, 34, died July 5 following incident in Nanoose Bay

Parksville man, 95, gets lifetime achievement award for civil rights work

Bill Duncan worked with Martin Luther King Jr. in Chicago

71-unit rental apartment building proposed in downtown Parksville

Open house will take place before second reading of bylaw amendment

B.C. sees 25 new COVID-19 cases, community exposure tracked

One death, outbreaks remain in two long-term care facilities

VIDEO: Alberta man rescues baby eagle believed to be drowning in East Kootenay lake

Brett Bacon was boating on a lake in Windermere when he spotted the baby eagle struggling in the water

Vancouver Island business ad unintentionally features OK gesture linked to white supremacy

Innocuous ‘OK’ gesture in cleaning franchise advertisement gets flak on social media for ‘supposedly’ promoting white supremacy

Minivan driver’s speed a factor in fatal 2018 Malahat crash

Driver was travelling at 110 km/h in a construction zone

Comox Valley RCMP looking for missing woman

Ami Guthrie was last seen in Courtenay in early July

Conservationists raise concerns over state of care for grizzly cubs transferred to B.C. zoo

‘Let them be assessed now before their fate is sealed,’ urges B.C. conservationist Barb Murray

B.C.’s COVID-19 job recovery led by tourism, finance minister says

Okanagan a bright spot for in-province visitor economy

National Kitten Day aka the ‘purrfect’ day to foster a new friend

July 10 marks National Kitten Day, a special day to celebrate all things kittens

Lower Mainland YouTubers claim to be Kelowna display toilet ‘poopers’

RCMP can not speak to legitimacy of video, will be investigating

Most Read