Wettlaufer Inquiry Finds Ontario's Care Homes Never Caught a Killer Nurse
Commissioner Eileen Gillese blamed systemic weaknesses, not any one person, for letting Elizabeth Wettlaufer kill eight residents undetected, and made 91 recommendations.
Published
No one caught Elizabeth Wettlaufer. That was the hardest finding in the report Ontario's public inquiry released in Woodstock on July 31, 2019. The former nurse had killed eight seniors in her care at two long-term care homes in southwestern Ontario, and had she not confessed, the inquiry concluded, her crimes would have gone undetected.
Commissioner Eileen Gillese spent two years on the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System. Her four-volume final report placed the blame not on the failure of any single person or organization but on systemic vulnerabilities across the province's more than 600 long-term care homes. "The finding is significant because it tells us that there is no simple fix in terms of avoiding similar tragedies in the future," she said. "Systemic issues demand a systemic response."
Wettlaufer had pleaded guilty in June 2017 to eight counts of first-degree murder, four of attempted murder and two of aggravated assault for injecting seniors with fatal doses of insulin. The murders took place between 2007 and 2014 at Caressant Care in Woodstock and Meadow Park in London. She was serving life in prison with no chance of parole for 25 years.
Gillese used her remarks to dismantle the idea that the killings were acts of mercy. Wettlaufer herself never claimed that, the commissioner said. By her own account, she killed because she was angry about her career, her responsibilities and her life, and afterward she felt a release, a sense of euphoria. Gillese said she committed the crimes for her own gratification and for no other reason. The report was deliberately not named after her, to deny her any notoriety.
The inquiry made 91 recommendations, built around four strategies: prevention, awareness, deterrence and detection. It called for stronger medication management, a limited supply of insulin in long-term care homes, and provincial grants of $50,000 to $200,000 per home to track and audit drugs. It asked the province to study how many registered staff each shift actually needs and to fund more if the study found a shortage. Homes were told to check references and backgrounds closely when a résumé showed gaps or a candidate had been fired, and directors of nursing were to make unannounced spot checks on evening, night and weekend shifts. The College of Nurses was to train its intake investigators on the phenomenon of the health care serial killer, and the public was to be made aware that such killers exist.
The first two volumes were dedicated to the victims and the people who loved them. Ontario's Minister of Long-Term Care, Merrilee Fullerton, promised to act on the recommendations and to provide new money, though she named no figure. The province would also pay for two years of counseling for the families and for Wettlaufer's surviving victim.
Not everyone in the room was satisfied. One man, Darryl Randal, shouted that the report should have named names and accused the inquiry of protecting individuals. "People died, people died because of their incompetence," he said.
Beverly Bertram saw it differently. She was 68 and receiving care at home when Wettlaufer attacked her, and she survived. "It's not their job to lay blame, it's their job to fix the problem and that is what they're doing," she said. She was most pleased by the call for more thorough reference checks on health care workers, including those who treat people in their own homes. Laura Jackson, a longtime friend of Maurice Granat, 84, one of the residents Wettlaufer murdered, said the inquiry had met the families beforehand and asked what they wanted from it. Most of it, she said, was in the report.
Sources
- 91 recommendations in Wettlaufer inquiry report, Blackburn News (Sarnia News Today)