A long-awaited report on Elizabeth Wettlaufer’s murder spree in nursing homes has warned that a health-care serial killer can strike again.
“We cannot assume that because Wettlaufer is behind bars, the threat to the safety and security of those receiving care in the long-term-care system has passed,” Justice Eileen Gillese said while revealing her report today.
“To avoid similar tragedies in the future, it is critical that awareness is developed throughout the health-care system of the possibility that a health-care provider could intentionally harm those in their care,” she added, calling health-care serial killers a “phenomenon.”
Gillese’s four-volume report calls for sweeping changes to fix the “systemic vulnerabilities” that allowed Wettlaufer, a registered nurse, to kill nine people in two southwestern Ontario nursing homes between 2007 and 2016. Her crimes only stopped when she decided, unprompted, to turn herself in and confess.
The report’s 91 recommendations include calls for more intensive ministry oversight of nursing homes, more ministry funding for training and education of nursing home staff, increasing the number of registered nurses and staff in the homes, and government grants of up to $200,000 per home to make infrastructure and other changes to better secure medication. Wettlaufer murdered her victims with overdoses of insulin.
The report does not say how much extra ministry funding all the recommendations would require. But with 626 nursing homes in Ontario, the price tag is significant.
“The best way to prevent similar tragedies is to strengthen the long-term-care system and encourage excellence in residence care,” said Gillese, a justice on Ontario’s Court of Appeal.
Gillese revealed her inquiry’s report in Woodstock, Ont., home of the Caressant Care long-term facility, where she killed seven of her victims. Families of the victims were able to see the report before it was publicly released at noon, and then packed a hotel room to hear Gillese give a summary of the findings.
“This report is dedicated to the victims and their loved ones. Your pain, loss and grief are not in vain,” the report says.
“The victims’ family members and loved ones continue to struggle with feelings of sadness, anger, guilt, grief, anxiety, fear, depression and betrayal,” it adds. “Some have lost trust in health-care professionals, people in positions of authority and the government. Others have withdrawn from family and friends, and most have difficulty eating, sleeping and focusing.”
The report summarizes the litany of errors and oversights that allowed Wettlaufer to continue killing undetected. But it makes no findings of misconduct because the offences “were the result of systemic vulnerabilities in the long-term-care system.”
“What this finding highlights is that there is no simple ‘fix.’ We cannot point our fingers at any given individual or organization, identify the shortcomings we find there, and end the threat posed by wrongdoers such as Wettlaufer by remedying those shortcomings.
“Systemic issues require a systemic response,” the report says.
It describes Ontario’s long-term-care system as “strained but not broken” and says “there is no need to jettison the existing regulatory system and start over.” But nursing homes need to be supported to comply with existing regulations.
The report recommends that nursing homes build a more stable supply of staff and limit their use of agency nurses who roam from one workplace to another.
It calls on the government to study the adequate levels of registered nurses and other staff in nursing homes. The study should be tabled in the legislature by July 31, 2020.
More funding to nursing homes should be provided if the study finds more staff are needed for residents’ safety, the report says.
Gillese made a point of “debunking” the myth that Wettlaufer performed “mercy killings.”
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“When Wettlaufer committed the offences, the victims were still enjoying their lives and their loved ones were still enjoying time with them. It was not mercy to harm or kill them,” Gillese said, noting Wettlaufer confessed she murdered out of anger about her career and the sense of “euphoria” she felt when killing.
“Wettlaufer is a serial killer. Like other serial killers, she committed the offences for her own gratification and for no other reason.”
Wettlaufer was a rogue nurse from the start. She was fired from her first job at a hospital in 1995 after being caught high on drugs, which she admitted to stealing on her overnight shift.
The next two decades saw Wettlaufer disciplined dozens of times for medication errors, poor treatment of residents under her care, conflicts with co-workers, and generally shoddy work.
During her seven years at Caressant Care, until she was fired in March 2014 for a serious medication error, managers of the home noted more than 130 complaints against Wettlaufer from residents and co-workers in her employment file.
Yet after Caressant reported her firing to the College of Nurses — responsible for keeping the public safe from bad nurses — the college didn’t investigate her. Wettlaufer was left with a spotless public record and went on to kill two more people at the Meadow Park nursing home in London, Ont., and try to kill two more.
Wettlaufer pleaded guilty to killing eight patients under her care at Caressant Care and Meadow Park nursing home in London. While serving a life sentence she confessed to killing a ninth person, a resident at Meadow Park.
Since 1970, 90 health-care serial killers have been convicted in the U.S., Britain and Western European countries.
Wettlaufer’s crimes, Gillese said, cast “an undeserved stain” on people working in long-term care.
The report calls on the College of Nurses, responsible for protecting the public from bad nurses, to educate its staff on the possibility that health-care providers might intentionally harm patients, and revise its procedures with that in mind.
The college must also strengthen its investigation process by better training its staff.
Coroners must also improve how they investigate nursing home deaths, the report says. They should keep track of “patterns and unusual trends” in deaths in long-term-care homes, and use the information to help decide when to investigate.
The public inquiry heard from 50 witnesses in the summer of 2018, held dozens of further consultations with experts and long-term-care officials, and reviewed more than 42,000 documents containing some 400,000 pages.
Sandro Contenta is a reporter and feature writer based in Toronto. Follow him on Twitter: @scontenta