Systemic Failures in Long-Term Care Allowed Wettlaufer to Commit Crimes

Elizabeth Wettlaufer is escorted by police from the courthouse in Woodstock, ON., on June 26, 2017. A public inquiry examining the case of a serial-killer nurse who preyed on elderly patients is set to deliver its report on July 31, 2019. (Dave Chidley/The Canadian Press)

WOODSTOCK, ON—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 inquiry said those failures stem in part from a lack of awareness on the risk of staff members deliberately hurting patients.

“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 admitting to killing eight patients with insulin overdoses and attempting to kill four others. She was arrested after confessing to mental health workers and police.

The Recommendations

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 members to divert medication.

Here are some key recommendations from the 91 listed in the report.

It calls on the province to launch a three-year program allowing each of Ontario’s more than 600 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 staff pharmacist or pharmacy technician, among other measures, the report said.

In order 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 of next year, 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 facilities, informed by a document submitted by homes after a resident dies, the report said. The form itself should be redesigned to contain more information and be submitted electronically so unusual trends can be spotted.

Long-term care facilities should also improve their analysis of medication-related incidents, including establishing specific strategies for those related to possible insulin overdoses, it said. Reasonable steps should also be taken to limit insulin supply.

Homes should also adopt a hiring process that involves robust reference and background checks when an applicant has gaps in their resume or has been fired from a previous job, the document said.

Justice Eileen E. Gillese, Commissioner of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System delivers her report in Woodstock, ON., July 31, 2019. (Geoff Robins/The Canadian Press)

A Chronology of the Events

Here is a chronology of the events in the Elizabeth Wettlaufer case, based on police information, court documents, and public obituaries.

• June 25, 2007 - Dec. 31, 2007: Wettlaufer injected 87-year-old Clotilde Adriano with insulin at the Caressant Care long-term-care home in Woodstock, ON., committing what police called an aggravated assault. Adriano died on July 30, 2008, at the age of 88. Police said her death is not attributed to Wettlaufer. Adriano was a widowed mother of two and grandmother to five.
• June 25, 2007 - Dec. 31, 2007: Wettlaufer injected Albina Demedeiros with insulin at Caressant Care, committing what police have called an aggravated assault. Demedeiros died in hospital on Feb. 25, 2010, her 91st birthday. Police said her death was not attributed to Wettlaufer. Demedeiros was predeceased by nine of her 10 siblings, including victim Clotilde Adriano.
• Aug. 11, 2007: Wettlaufer used insulin to murder James (Jim) Silcox at the Caressant Care home. The 84-year-old was a Second World War veteran of the Royal Canadian Army Service Corps. He was a married father of six.
• Dec. 22, 2007 - Dec. 23, 2007: Wettlaufer killed Maurice (Moe) Granat with insulin at the Caressant Care home. The 84-year-old father of two was a longtime mechanic and automotive body man in Tillsonburg, ON.
• Jan. 1, 2008 - Dec. 31, 2009: Wettlaufer injected Caressant Care resident Michael Priddle, 63, with insulin ‘‘with intent to murder.’' Priddle died at the home at the age of 64, with his family by his side, at an undisclosed date. Police have said his death is not attributed to Wettlaufer. Priddle was survived by his wife of 41 years as well as two children.
• Sept. 1, 2008 - Dec. 31, 2008: Wettlaufer injected Caressant Care resident Wayne Hedges with insulin ‘‘with intent to murder.’' The 57-year-old Hedges died at the long-term care home on Jan. 24., 2009. Police say his death is not attributed to Wettlaufer. Hedges was survived by his parents and two siblings and predeceased by a brother.
• Oct. 13, 2011 - Oct. 14, 2011: Wettlaufer killed 87-year-old Gladys Millard with insulin at the Caressant Care home. Millard, a widowed mother of two, was originally from Nova Scotia. She was a longtime member of Knox Presbyterian Church and a member of the Rose Rebekah Lodge in Woodstock.
• Oct. 25, 2011 - Oct. 26, 2011: Wettlaufer murdered 95-year-old Helen Matheson with insulin at the Caressant Care home. Matheson, a widowed mother of two sons, was a longtime United Church member in Innerkip, ON.
• Nov. 6, 2011 - Nov. 7 , 2011: Wettlaufer used insulin to murder 96-year-old Mary Zurawinski at the Caressant Care home.
• July 13, 2013 - July 14, 2013: Wettlaufer murdered 90-year-old Helen Young with insulin at the Caressant Care home.
• March 22, 2014 - March 28, 2014: Wettlaufer murdered 79-year-old Maureen Pickering at Caressant Care with insulin. The widow was a former native of Tillsonburg, ON.
• Aug. 23, 2014 - Aug. 31, 2014: Wettlaufer used insulin to kill 75-year-old Arpad Horvath. He lived at a Meadow Park facility in London, ON. The married father of two was the owner of Central Tool and Die of London and active in the local Hungarian club.
• Sept. 1, 2015 - Sept. 30, 2015: Wettlaufer injected 77-year-old Sandra Towler with insulin ‘‘with intent to murder’' at the Telfer Place retirement home in Paris, ON.
• Aug. 1, 2016 - Aug. 30, 2016: Wettlaufer injected 68-year-old Beverly Bertram with insulin ‘‘with intent to murder’' while the woman was living at a private residence in Ingersol, ON.

Elizabeth Wettlaufer, a nurse accused in the murder of 8 elderly patients in Southern Ontario leaves the courthouse in Woodstock, Ontario, Canada October 25, 2016.
(Geoff Robins/AFP/Getty Images)

Seven of the patients Wettlaufer killed were residents of Caressant Care in Woodstock, ON., the community where the report was released Wednesday.

Wettlaufer was fired from Caressant Care in 2014 after multiple medication errors and was then hired by the Meadow Park care home in London, ON.

Wettlaufer told lawyers with the inquiry that she chose insulin to commit her crimes because it wasn’t tracked where she worked.

The inquiry also heard evidence that even if full death investigations had been performed on all her victims, there likely would not have been evidence that they were deliberately injected, largely due to how insulin is processed in the body.

The judge, police, and prosecutor in her criminal case all said she wouldn’t have been caught without her confession.

That finding is echoed in the inquiry’s report, which noted nothing at the homes raised the suspicion of ministry inspectors or coroners who conducted death investigations for some of Wettlaufer’s victims.

Gillese stressed that unlike what some may believe, Wettlaufer’s crimes were not mercy killings, noting that “like other serial killers, she committed the offences for her own gratification and for no other reason.”

The commissioner also said the system is still vulnerable to health-care serial killers.

“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,” she said.

The report said many of its recommendations cost little or nothing to implement, but for those with a price tag attached, the cost is proportional to the threat posed by health-care serial killers.

It said the government should report back in a year on what steps it has taken to address the recommendations, and should provide free counselling to the victims’ families for two years.

“The delivery of this report forces us, as a society, to decide if we are willing to make the financial investment necessary to improve not only the safety and security of older Ontarians but also the quality of their lives,” it said.