VIDEO: Inquiry Finds Systemic Failures Allowed Wettlaufer's Crimes


A commission blames systemic failures in long-term care for allowing Elizabeth Wettlaufer to carry out her crimes without raising questions. 

In a report released Wednesday, the commission for the public inquiry led by Ontario appeals judge Eileen Gillese says those failures stem in part from a lack of awareness on the risk of staff members deliberately harming patients.

Wettlaufer, a former nurse, is serving a life sentence after pleading guilty in 2017 to killing eight patients with insulin overdoses and attempting to kill four others.


(Image courtesy of CTV News)

She is known as Canada's "first known health-care serial killer"

The commission's report lays out 91 recommendations aimed at preventing such crimes, including measures to raise awareness of serial killers in health care, and make it harder for staff members to divert medication.

It calls on Ontario's Ministry of Health and Long-term Care to, among other things, give each facility a grant of $50,000 to $200,000 to improve oversight of the administration of drugs.

It also says more deaths of patients in long-term care facilities should be investigated.

Some other key recommendations include; 

  • The ministry should refine its performance assessment program for long-term care facilities to better identify those struggling to provide a safe and secure environment.
  • It should conduct a study to determine adequate levels of registered nursing staff in long-term care facilities and table the findings by July 31, 2020. If the study shows a need for additional staffing to ensure residents' safety, homes should receive more government funding.
  • Long-term care homes should analyze medication-related incidents and adverse drug events through a framework that includes screening for possible intentional harm.
  • Homes should document and track the use of glucagon, a hormone that raises a person's blood sugar, to identify patterns and trends.
  • Facilities should require that directors of nursing conduct unannounced spot checks on evening and night shifts, including weekends.
  • Homes must maintain a complete discipline history for each employee so management can easily review it while making discipline decisions.
  • The Office of the Chief Coroner and the Ontario Forensic Pathology Service should replace the current form submitted when a long-term care patient dies with a redesigned, evidence-based death record that includes whether aspects of the resident's decline or death were inconsistent with the expected medical trajectory.