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

LETTER: Miles put on the car causes North Island driver to reflect

“Up here in Port McNeill we are so blessed with nature’s tranquillity all around us”

Collaborative effort removes salmon farms from BC coast

The first farms to be removed were those in closest to the Ahta and Viner Rivers.

North Island Concert Society: Marc Atkinson Trio coming to the Civic Centre

The concert takes place at 7:30 p.m. on Jan. 18 at the Port Hardy Civic Centre.

MP Blaney welcomes feedback on medical assistance in dying legislation

Over the next two weeks the Government of Canada is holding consultations… Continue reading

Picture perfect: Get the most from your wedding photography

Stop by the Comox Community Centre on Jan. 26 from 11:00 a.m. to 4:00 p.m.!

‘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

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

Blue Monday is a myth but seasonal affective disorder and the winter blues are real

Canadian Mental Health Association says weather can affect mood

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

Ice chunk from truck crushes vehicle windshield on Vancouver Island

None injured, but Nanaimo RCMP say there can be fines for accumulations of ice and snow

Calls for dialogue as Coastal GasLink pipeline polarizes some in northern B.C.

Coastal GasLink is building the 670-kilometre pipeline from British Columbia’s northeast to Kitimat on the coast

Most Read