Elizabeth Wettlaufer was a registered nurse in Ontario from 1995 to 2016. Between 2007 and 2016 she deliberately gave insulin overdoses to fourteen people in her care, most of them elderly residents of long-term care homes in Woodstock, London and Paris. Eight of them died. On June 1, 2017, she pleaded guilty in Woodstock to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault, and on June 26 she was sentenced to life in prison with no chance of parole for twenty-five years.
None of the deaths had been treated as suspicious. Families, co-workers, managers, provincial inspectors, coroners and the nurses' regulator all missed what she was doing, according to the public inquiry that followed. The offences came to light only because, in September 2016, she checked herself into the Centre for Addiction and Mental Health in Toronto and told her psychiatrist what she had done. The sentencing judge, the police and the prosecutors all said she would never have been caught otherwise, and the inquiry's commissioner reached the same conclusion.
She was born Elizabeth Tracey Mae Parker on June 10, 1967, and grew up in and around Woodstock, a small city in Oxford County, in a religious family. She studied journalism for a year, then spent four years at London Baptist Bible College and earned a bachelor's degree in religious education. She went back to upgrade her high school science and mathematics, completed the three-year nursing program at Conestoga College's Stratford campus, and received her diploma in June 1995. That year she became a registered nurse and a member of the College of Nurses of Ontario, the body that licenses and disciplines nurses in the province.
Her first nursing job was at Geraldton District Hospital in northern Ontario, where she worked from June to October 1995. In September 1995 she collapsed at work after taking a controlled drug from the hospital's supply. A Canadian Press report on the later inquiry hearings described the episode as an apparent suicide attempt. The hospital fired her and, as the law required, reported her to the College. The College put conditions on her licence, including treatment for substance abuse and reporting requirements, and monitored her. At the 2017 disciplinary hearing the College's lawyer said it had found at the time that she had not tried to harm patients. The inquiry report says the conditions were lifted in May 1998.
For most of the next decade she did not work as a nurse. After a period in 1996 at a rest home in Woodstock, she worked from June 1996 to June 2007 as a support worker for Christian Horizons in Woodstock. She was hospitalized for mental health reasons in 2006. The inquiry described her career as marked by performance problems, difficulties with colleagues and frequent changes of job, and said that at work she was sometimes successful but was also seen at times as sloppy and lazy and given to inappropriate comments. Her personal life, it said, included failed relationships, mental health problems and addiction.
The Canadian Encyclopedia records that she married in October 1997, that they separated in January 2007 and divorced in 2008, and that she struggled with alcohol and opioids. According to Canadian Press reporting of the documents filed with her guilty plea, the marriage ended early in 2007 after her husband came to suspect she was having an affair with a woman. Staff at the Centre for Addiction and Mental Health later diagnosed major depressive disorder, borderline personality disorder and antisocial behaviour in adulthood, according to the Encyclopedia.
In June 2007 she was hired as a registered nurse at Caressant Care, a long-term care home in Woodstock run by a private company that, in 2016, operated fifteen homes in Ontario. Her only reference when she applied came from her support work job; the home's director of nursing told the inquiry in 2018 that she had not known about the Geraldton episode.
Within weeks of starting, she began to harm residents. Between late June and the end of December 2007 she injected two elderly residents of the home with insulin. Both survived, and the injections were later charged as aggravated assault. On August 11, 2007, according to the facts read in court, she killed James Silcox, 84. He was the first person she killed.
James Silcox, known as Jim, was a Second World War veteran who had served in the Royal Canadian Army Service Corps. He had worked at a tube manufacturing plant and was a married father of six. He had diabetes and Alzheimer's disease and was recovering from hip surgery when she killed him. A man of faith, he had expected God to decide when he would die, his family said in court. His wife died three weeks after learning that he had been murdered.
In December 2007 she killed Maurice Granat, 84, who died on December 23. Known as Moe, he was a father of two who had worked for many years as a mechanic and auto body man in Tillsonburg. A close friend told the court he had been one of the best people she knew and a father figure to her, and that after learning how he died she became so depressed that she lost her job.
In 2008 and 2009 she tried to kill two more residents of the home, both of them men. Both survived. Canadian Press reporting of the plea documents said her confessions to other people stopped for a time after these attempts, but the killings resumed. A relative of one of the men told the sentencing hearing he was still working through his anger. Both men later died of causes that police said were not attributed to her.
The home's director of nursing told the inquiry that Wettlaufer was disciplined several times for poor performance: failing to document a new resident's admission, failing to give eye drops properly and neglecting duties in ways that left extra work for colleagues. She said the home regarded her as an underperformer who made relatively minor errors, and that Wettlaufer "had some very good sides." In August 2012, according to documents before the inquiry, administrators raised concerns about patient safety and warned that they would ask the College to review her fitness to practise if she did not improve. Wettlaufer told her employers she was caring for her father, who had Alzheimer's disease, and that a change in her mental health medication had left her not feeling like herself.
In October and November 2011 she killed three residents of Caressant Care.
Gladys Millard, 87, died on October 14, 2011. Born in Nova Scotia, she was a widowed mother of two, a longtime member of Knox Presbyterian Church and a member of the Rose Rebekah Lodge in Woodstock. Her niece described her in court as a well-known seamstress in the city. Her daughter told the court that it broke her heart to learn that her mother had been killed by a large dose of a medication she did not need.
Helen Matheson, 95, died on October 27, 2011. She was a widowed mother of two sons and a longtime member of the United Church in Innerkip, a village near Woodstock. A friend who had known her since 1969 called her a strong woman and a substitute mother. Her son said in a statement read by his wife that he had wondered whether he missed warning signs, and that his health had suffered since he learned how she died.
Mary Zurawinski, 96, died on November 7, 2011. Her family said in court that she had been determined to reach her hundredth birthday, and that they had had to begin grieving all over again when they learned she had been killed on purpose. They spoke of hatred and rage, and of depression, anxiety and trouble at work in the years since.
On July 14, 2013, Helen Young, 90, died after Wettlaufer injected her the day before. Helen Young had grown up in Scotland and came to Canada after marrying a man from Calgary. She had no children, loved her dogs, and had been widowed in 1988. Her niece's statement, read by the Crown, said she had hugged and thanked Wettlaufer after her aunt's death, not knowing who she was, and that the memory stayed with her.
In March 2014 she killed Maureen Pickering, 79, who died on March 28. A widow originally from Tillsonburg, she had Alzheimer's disease. Friends who had chosen Caressant Care for her described her in court as intelligent and elegant, and said they felt terrible guilt and hoped the case would lead to better care for the elderly.
Days before she killed Maureen Pickering, on March 20, 2014, Wettlaufer made a serious medication error involving insulin that did not involve any of her victims; the College's 2017 hearing was told she had given a resident insulin prescribed for another. Caressant Care ended her employment that month after a series of medication errors. Documents filed at the inquiry showed that the home gave her a reference letter and a settlement of $2,000. The director of nursing told the inquiry that, knowing what she knew later, she would never have given the reference.
The home filed a termination report with the College of Nurses dated April 17, 2014. It summarized her performance problems and medication errors and referred the College to her personnel file. The College decided that no investigation was needed and placed no restrictions on her licence. It took no step beyond what the inquiry called "banking with notice": the report was kept on file in case further concerns arose. The inquiry concluded that this decision showed the College had no serious concerns about the care she gave. Recommendations 40 to 49 of the inquiry's report were later directed at the College.
Within a month she had a new job. On April 22, 2014, she started as a registered nurse at Meadow Park, a long-term care home in London. In August 2014 she killed Arpad Horvath, 75, a resident there. He died in hospital in London on August 31, 2014.
Arpad Horvath was a married father of two who owned a tool and die business in London and was active in the city's Hungarian club. His son told the sentencing hearing that his father had been his teacher, his hero and his best friend. His daughter, Susan Horvath, became one of the most public voices among the families. At the guilty plea she said she could not forgive Wettlaufer and called for better oversight of long-term care.
Wettlaufer resigned from Meadow Park on September 25, 2014, effective October 15, saying she needed help with an illness.
From January 2015 to August 2016 she worked through a nursing agency based in Brantford. Through the agency she was placed at Telfer Place, a long-term care facility in Paris, Ontario, where she worked from February 2015 to April 2016. In September 2015 she tried to kill a woman who lived there. The woman survived.
In June 2016 she was offered work with a home care provider in Oxford County, and she started in July. In August 2016 she tried to kill a woman in her care at the woman's own home in Ingersoll. It was the only one of the offences that did not take place in a licensed long-term care home; the inquiry noted that she was providing publicly funded nursing care there. The woman survived. The Canadian Encyclopedia says she was the only one of the fourteen people in the case still alive at the time of sentencing. She told the court that she was still afraid to sleep at night and that she had worried Wettlaufer would get out and finish what she had started. The inquiry wrote that she had been profoundly affected, became afraid to go to bed or to have visitors, and suffered in her personal relationships.
Over the years Wettlaufer told several people what she was doing, and none of them stopped her. The agreed facts and hospital records filed with her guilty plea, as reported by The Canadian Press, set out the list. A former girlfriend, told that she had already killed two people, threatened to report her if she did it again. A student nurse whom she told about the deaths said she meant to report it, but Wettlaufer talked her out of it by saying no one would believe her. She confessed to a pastor and his wife at their kitchen table; they prayed over her and told her they would go to the police if she killed again. In 2014 she told a criminal lawyer everything, and the lawyer advised her that it was in her interest to stay silent and to get help for her mental health. A Narcotics Anonymous sponsor and a former boyfriend both dismissed what she said.
During those years she was also in psychiatric care, including a stay in a local psychiatric unit and visits to a psychiatrist in Woodstock. The Canadian Press reported that the plea documents gave no indication whether any of her psychiatric caregivers learned what she had done.
Days after the attack in Ingersoll in August 2016, she learned that she was to be reassigned to work with children who had diabetes. According to the plea documents, the prospect frightened her because she did not believe she could control her impulses. She drove toward Quebec, meaning to run away, and then turned back. For about two weeks she pretended to go to work so that her parents would not find out, and then she quit her nursing jobs. "I didn't want to hurt anybody any more, so I quit my job," she later told police. An expert on killings in health care who testified at the inquiry said the main difference between Wettlaufer and other such offenders was that she confessed before she was due to work with children.
On September 16, 2016, she checked herself into the Centre for Addiction and Mental Health in Toronto. She went there, the plea documents said, so that her confessions would be acted on. She told her psychiatrist that over the previous nine years she had harmed and killed people with insulin, and she wrote out a four-page confession by hand, without notes or records. The hospital called Toronto police, a source told Global News, and officers went there to interview her. Toronto investigators determined that none of the incidents had happened in Toronto and passed the information to the police services where they had. Her psychiatrist notified the College of Nurses on September 29, 2016, the first word the College had of any criminal conduct.
On September 30, 2016, Wettlaufer emailed and telephoned the College to say she was unfit to practise and wanted to resign. She told an intake investigator that she had deliberately given insulin overdoses to fourteen patients, though she said she was not sure whether the eight deaths were directly or indirectly linked to what she had done. The College opened an investigation at once but was asked by the Crown to stand back so that police could proceed.
The criminal investigation began in Woodstock on September 29, 2016, and expanded to London and to Oxford and Brant counties. It was led by a major case manager from the Ontario Provincial Police's Criminal Investigation Branch, working with the Woodstock and London police services and the OPP's Oxford and Brant detachments. She later gave Woodstock police a videotaped account that ran about two and a half hours. A Crown attorney later said she told the story "with great recall and in great detail." A discharge document from the hospital is dated October 5, 2016, and a court-ordered peace bond dated October 6 required her to continue mental health treatment, keep away from insulin and other drugs not prescribed to her, avoid alcohol, stay out of care work, hospitals and long-term care homes, and keep a curfew. On October 14 the OPP announced that a suspect had been identified and that there was no further risk to the public.
The Canadian Encyclopedia gives October 24, 2016, as the date of her arrest. On October 25, at a news conference held by the OPP and the London and Woodstock police services, she was charged with eight counts of first-degree murder. Police said only that a drug had been given to patients at two nursing homes, in Woodstock and London, between 2007 and 2014; they did not name it. Woodstock's police chief said investigators were confident that all the victims had been identified and their families told. She appeared in court in Woodstock that day and was remanded in custody. Caressant Care said in a statement that the investigation concerned a former nurse who had left about two and a half years earlier, and that it deeply regretted the grief and stress the case had caused families.
In January 2017 police exhumed the bodies of Arpad Horvath and Helen Matheson for forensic examination. On January 13, 2017, the OPP announced six more charges: four counts of attempted murder and two of aggravated assault. Police said four of the six people named in those counts had since died, and that their deaths were not attributed to her.
On June 1, 2017, in Woodstock, Wettlaufer pleaded guilty before Justice Bruce Thomas to all fourteen counts. She said "guilty" fourteen times and admitted she had used insulin in every case. When the judge asked whether she had meant to kill each victim, she answered, "Yes, your honour." By pleading guilty she gave up her right to a trial. Family members and friends filled the courtroom.
The Crown read the agreed statement of facts and played her videotaped confession. The court heard that she had not been under the influence of drugs or alcohol at the time of any of the offences, and that many of the victims had dementia. In her statements to police she said she had been overwhelmingly angry about her career, her responsibilities and her life. She described a "red surge" that she came to identify with God speaking to her, an urge that eased only after she had given an overdose, and a laughing fit afterward. "I honestly felt that God wanted to use me," she said, and she also said that part of her thought it was the devil. Some of the killings, she said, were about returning people to God. An expert who later testified at the inquiry summarized her accounts this way: sometimes she was set off at work by a difficult patient, sometimes by the internal surge, and there was never a long period of planning.
The sentencing hearing took place in Woodstock on June 26, 2017. The court heard victim impact statements from relatives and friends of those she killed and harmed. Many spoke of grief, of anger, and of guilt for having placed a parent or relative in a care home or for having missed warning signs. In the Silcox family, relatives said the case had turned siblings against one another. The judge told the families they could not blame themselves.
Wettlaufer apologized briefly. She said she was truly sorry for the people she had injured and killed, and that "sorry" was far too small a word.
Justice Thomas accepted the joint submission of the Crown and the defence. On each count of first-degree murder he imposed life imprisonment with no eligibility for parole for twenty-five years. He imposed ten years on each count of attempted murder and seven years on each count of aggravated assault, all to be served at the same time. He said she was far from an angel of mercy, describing her instead as a figure of death who had passed over her victims, and he said that without her confessions the offences would never have been brought to justice. The Canadian Encyclopedia says she can first apply for parole in 2041.
On July 25, 2017, a five-member discipline panel of the College of Nurses of Ontario found her guilty of professional misconduct and revoked her certificate of registration. She did not attend the hearing in Toronto. The College's lawyer relied on the agreed statement of facts and on her confession to police. The panel's chair called it the most egregious and disgraceful conduct the panel had ever considered.
In March 2018 she was moved from Grand Valley Institution for Women in Kitchener, which CTV London described as a maximum-security women's prison, to the Institut Philippe-Pinel in Montreal, which has a psychiatric unit for women serving federal sentences. In October 2018 Public Safety Minister Ralph Goodale said it was for mental health reasons and that public safety was the overriding consideration in such decisions. A government official told Global News that such transfers happen only for severe psychiatric problems beyond what an ordinary prison can manage. The Conservative deputy leader, Lisa Raitt, said victims' families deserved better.
In March 2019 Correctional Service Canada wrote to Susan Horvath to tell her that Wettlaufer had been returned to Grand Valley Institution, CTV London reported.
In July 2017 a daughter of James Silcox and Arpad Horvath's son filed civil suits against Wettlaufer and the two homes where the murders took place. The Silcox claim alleged that negligent oversight and management at Caressant Care let her work undetected and that her crimes were fraudulently concealed. Neither home commented. In September 2018 Susan Horvath filed a $12.5 million claim against eighteen defendants, among them Meadow Park, Caressant Care, people in management at both homes and the Ontario Nurses' Association, alleging that they had evidence she should not have been practising and failed to protect vulnerable residents. Caressant Care and the union said they had not been served. Susan Horvath said her priority was change to the system rather than money, and she urged nurses and personal support workers to report anything that worried them.
On August 1, 2017, the Ontario government established the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System by order in council. Its commissioner was Eileen E. Gillese. It was asked to examine the events that led to the offences, the circumstances and factors that allowed them, and the policies, practices and oversight systems involved. Hearings in 2018 were held in St. Thomas. The inquiry did not compel Wettlaufer to testify, because her confessions and an interview she gave inquiry lawyers were already in evidence. In that interview she said she had chosen insulin because, unlike narcotics, it was not closely tracked where she worked.
Witnesses described how she went unnoticed. The director of nursing at Caressant Care broke down on the stand. Dr. Michael Pollanen, Ontario's chief forensic pathologist, testified that autopsies would probably not have revealed intentional insulin overdoses. Beatrice Crofts Yorker, a researcher at California State University, Los Angeles, who has studied killings by health care workers for decades, said Wettlaufer had given more detail about her crimes than any other such offender and that there had been no clusters of deaths or rises in incidents that supervisors or software could have flagged.
Commissioner Gillese released her four-volume report, about 1,500 pages long, in Woodstock on July 31, 2019. It was dedicated to the victims and their families. She reached three principal findings. First, she said she had no hesitation in concluding that the offences would not have been discovered without Wettlaufer's confession. Second, the offences resulted from systemic vulnerabilities in the long-term care system, not from individual or organizational misconduct, so she made no findings of misconduct against anyone. Third, the system was strained but not broken, and its regulatory framework was a sound base to build on. The report said plainly that the killings were not mercy killings.
No one had suspected her: not residents, families, co-workers or managers, not the provincial ministry's inspectors and complaint process, not the coroners who looked into some of the deaths, and not the College. The report named the vulnerabilities as medication management, staffing levels, the use of agency nurses, oversight of home care, and the way deaths were reported and investigated. It also described the toll on others: families who felt sadness, anger, guilt and betrayal and lost trust in health professionals and government; communities that were still grieving; and staff who had worked alongside her and were, in the report's word, shattered.
The report made 91 recommendations, grouped under four strategies: prevention, awareness, deterrence and detection. They included a new unit to help homes adopt best practices, better training and supervision of staff, steps on agency nurses and home care, a call to share Ontario's experience of what the report called the healthcare serial killer phenomenon with other jurisdictions, more registered staff, stronger medication management, better analysis of possible insulin overdoses, grants of up to $200,000 per home for infrastructure changes, a study of staffing levels, an overhaul of the institutional patient death record with electronic filing so that clusters of deaths could be tracked, and better communication between the ministry and the College of Nurses. "It is not possible to detect or deter something unless you are aware it exists," Gillese said when she released the report.
Wettlaufer is serving concurrent life sentences for eight first-degree murders. She was last reported, in March 2019, to have been returned to Grand Valley Institution for Women in Kitchener.
Proven by final judgment, on her own guilty pleas: the first-degree murders of James Silcox, Maurice Granat, Gladys Millard, Helen Matheson, Mary Zurawinski, Helen Young, Maureen Pickering and Arpad Horvath; four attempted murders; and two aggravated assaults. No other offence has been charged. Four of the six people named in the attempted murder and aggravated assault counts died later, and police said their deaths were not attributed to her.
Her own doubts: when she resigned in September 2016 she told the College that she was not sure whether the eight deaths were directly or indirectly linked to what she had done. She later pleaded guilty to eight counts of first-degree murder and told the court she had intended to kill each victim.
Details that vary between sources: the date of James Silcox's death (the plea facts give August 11, 2007, as the date she killed him; a list based on death notices gives August 12; an October 2016 Global News report gives August 17); the end of her marriage (January 2007 in the Canadian Encyclopedia, February 2007 in Canadian Press reporting of the plea documents); how long her licence was restricted after 1995 (about a year in Canadian Press reporting of the College hearing, until May 1998 in the inquiry report); and whether Telfer Place was a retirement home (Canadian Press) or a long-term care facility (the inquiry report). Some news reports said she was convicted at trial; she was convicted on her own pleas, and there was no trial.
June 10, 1967: Elizabeth Tracey Mae Parker is born; she grows up in the Woodstock area.
June 1995: receives her nursing diploma from Conestoga College; registers with the College of Nurses of Ontario that year.
September 1995: collapses at work at Geraldton District Hospital after taking a controlled drug from its supply; fired and reported to the College, which puts conditions on her licence.
May 1998: the conditions are lifted (inquiry report).
June 1996 to June 2007: works as a support worker in Woodstock.
October 1997: marries.
Early 2007: her marriage ends.
June 2007: starts as a registered nurse at Caressant Care, Woodstock.
June to December 2007: injects two residents with insulin; both survive (aggravated assault).
August 11, 2007: kills James Silcox, 84.
December 2007: kills Maurice Granat, 84, who dies December 23.
2008 to 2009: tries to kill two men living at the home; both survive.
October 14, 2011: Gladys Millard, 87, dies.
October 27, 2011: Helen Matheson, 95, dies.
November 7, 2011: Mary Zurawinski, 96, dies.
August 2012: administrators raise patient safety concerns and warn of a referral to the College.
July 14, 2013: Helen Young, 90, dies.
March 20, 2014: a serious insulin error involving another resident.
March 28, 2014: Maureen Pickering, 79, dies.
March 2014: Caressant Care ends her employment.
April 17, 2014: Caressant's termination report to the College; the College takes no action beyond keeping it on file.
April 22, 2014: starts at Meadow Park, London.
August 31, 2014: Arpad Horvath, 75, dies.
September 25, 2014: resigns from Meadow Park, effective October 15.
January 2015 to August 2016: agency nursing, including Telfer Place, Paris (February 2015 to April 2016).
September 2015: tries to kill a woman at Telfer Place; she survives.
July 2016: starts home care work in Oxford County.
August 2016: tries to kill a woman at her home in Ingersoll; she survives.
September 16, 2016: checks herself into the Centre for Addiction and Mental Health in Toronto and confesses.
September 29, 2016: her psychiatrist notifies the College; the criminal investigation begins in Woodstock.
September 30, 2016: tells the College she is unfit to practise and resigns.
October 5 and 6, 2016: hospital discharge document; peace bond.
October 14, 2016: OPP announce that a suspect has been identified.
October 24, 2016: arrested (Canadian Encyclopedia).
October 25, 2016: charged with eight counts of first-degree murder; remanded in custody.
January 13, 2017: charged with four counts of attempted murder and two of aggravated assault.
January 24, 2017: two bodies exhumed.
June 1, 2017: pleads guilty to all fourteen counts in Woodstock.
June 26, 2017: sentenced to life with no parole eligibility for 25 years.
July 2017: the first civil suits are filed.
July 25, 2017: the College revokes her registration.
August 1, 2017: the public inquiry is established.
March 2018: moved to the Institut Philippe-Pinel, Montreal.
June to September 2018: inquiry hearings in St. Thomas.
September 2018: Susan Horvath files a $12.5 million claim.
March 2019: reported back at Grand Valley Institution for Women, Kitchener.
July 31, 2019: the inquiry's report and 91 recommendations are released in Woodstock.