Systemic vulnerabilities and not the failures of any one person or organization allowed serial killer former nurse Elizabeth Wettlaufer to murder eight seniors in her care at two southwestern Ontario long-term care homes without detection, according to the public inquiry into her crimes.
The four-volume final report aimed at preventing similar crimes and improving safety in the province’s more than 600 long-term care homes was released in Woodstock on Wednesday.
“The finding is significant because it tells us that there is no simple fix in terms of avoiding similar tragedies in the future,” said Inquiry Commissioner Eileen Gillese. “Systemic issues demand a systemic response. Systemic responses require collaboration, co-operation, and communication throughout the system.”
Elizabeth Wettlaufer is escorted into the Woodstock courthouse, January 13, 2017.
Compiled over two years, the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System noted that had Wettlaufer not confessed to her crimes they would have gone undetected.
“[This] tells us that to prevent similar tragedies in the future, we cannot continue to do the same things in the same ways in the long-term care system,” said Gillese. “Fundamental changes must be made -- changes that are directed at preventing, deterring, and detecting wrongdoing of the sort that Wettlaufer committed."
The report lists 91 recommendations centered around four strategies – prevention, awareness, deterrence, and detection. Among the key recommendations are better training for nursing home administrators on workplace investigations and reporting obligations, strengthening medication management systems, limiting the supply of insulin in long-term care homes to lessen the risk of abuse, and having the province look at whether staffing levels at long-term care facilities are adequate.
Another measure being recommended is raising awareness of the existence of health-care killers.
The report also recommends the provincial government create grants ranging from $50,000 to $200,000 per long-term care home to increase visibility around medication and improve tracking and audits of drugs. In addition to funding, it is recommended the province launch a study to be tabled in the legislature by July 31 of next year to determine the adequate number of registered staff needed on each shift. More funding should be made available to long-term care homes should the study conclude more staff is required.
Other key recommendations:
- Long-term care homes should limit and improve the use of agency nurses.
- The Ministry should strengthen education requirements relating to medical directors and nurse practitioners
- The Ministry should recognize and reward long-term care homes that have made demonstrated improvements in the wellness and quality of life of their residents
- Long-term care homes who have fallen below level 1 performance for two consecutive quarters should be identified by the Ministry and assisted to return to the level 1 classification.
- The College of Nurses should strengthen its intake investigation process by training its intake investigators on the healthcare serial killer phenomenon and how to conduct their inquiries in light of it
- Long-term care homes need to adopt a hiring/screening process that includes robust reference and background checking where there are gaps in a resume or the candidate’s previous employment was terminated, and close supervision in the probationary period
- The Director of Nursing at long-term care homes should be required to conduct unannounced spot checks on evening and night shifts, including on weekends
- Institutional patient death records need to be redesign so they are evidence-based; contain more and better information about a resident’s death
- Establish as a best practice that, at the preliminary consultation stage, coroners speak with the deceased’s family about the resident’s death and advise the family what they can do if the decision is made that no death investigation will be undertaken
In her remarks Wednesday, Gillese debunked myths that Wettlaufer's crimes were mercy killings.
“Wettlaufer herself never claimed she acted out of a sense of mercy,” said Gillese. “She said she committed the offences because she was angry about her career, her responsibilities and her life, and that after killing or harming she felt a release, a sense of “euphoria.”’
Gillese added that Wettlaufer committed these crimes for her own gratification and no other reason.
It was also noted that the report was not named after Wettlaufer as to not allow her any notoriety for her crimes.
Volumes one and two of the report are dedicated to the victims and their loved ones and states “your pain, loss, and grief are not in vain. They serve as the catalyst for real and lasting improvements to the care and safety of all those in Ontario’s long-term care system.”
A dedication to everyone who works in the long-term care system was included in volume three of the report.
At a news conference which followed the release of the report, Ontario Minister of Long-Term Care Merrilee Fullerton vowed to act on the recommendations.
“I take Justice Gillese’s recommendations to heart,” said Fullerton. “Over the next few weeks, we will be comprehensively reviewing the recommendations and developing a government-wide approach to address them.”
As recommended by Gillese, the province will deliver an update into its progress addressing issues in long-term care homes within a year. It will also provide counselling for Wettlaufer’s surviving victim and the families and loved ones of her victims for the next two years.
While not attaching a specific dollar figure, Fullerton did promise new funding to implement the recommendations.
“We need to create a long-term care system that treats people with dignity in a safe and comfortable environment,” said Fullerton. “Rest assured that as Minister of Long-Term Care I am coming to this file with a deeply held personal commitment to long-term care.”
One man angerly shouted after the report was unveiled that it should have “named names” and accused the inquiry’s core team of “protecting individuals” by not assigning blame.
“People died, people died because of their incompetence,” said Darryl Randal.
Beverly Bertram
However, Wettlaufer’s surviving victim Beverly Bertram was satisfied with the results of the inquiry.
“It’s not their job to lay blame, it’s their job to fix the problem and that is what they’re doing,” said Bertram, who was 68-years-old and receiving in-home care when Wettlaufer attacked her.
Out of all of the recommendations, she is most pleased with the call for more thorough reference checks for healthcare professionals, including those treating people in private residences.
Bertram went on to state that despite what happened, she feels sorry for Wettlaufer.
“She tried to get help, she fell through the cracks. She doesn’t deserve my pitty, but I’m sorry for her,” said Bertram.
Laura Jackson, a long-time friend of murder victim Maurice Granat, 84, said she was pleased with the simplicity of the recommendations.
“I like how they listened to what we had to say as survivors of Wettlaufer… They met with us before hand and asked what we wanted to see come out of this inquiry and most of what we wanted is in there,” said Jackson.
She also stressed that the government needs to ensure the recommendations are implemented as soon as possible, as safety and care in long-term care homes effects everyone.
“Everyone will either end up in a nursing home or know someone who is in a nursing home,” said Jackson. “So do you want to put a parent in a nursing home the way the nursing homes are now or do you want to put a parent in a nursing home after some of these recommendations have been implemented.”
To read the full final report and recommendations click here.