A public inquiry into the actions of a killer nurse said that Elizabeth Wettlaufer was able to carry out her crimes without suspicion because of a failure in healthcare oversight.
Wettlaufer is a former nurse, who confessed in 2017 to killing eight patients by giving them overdoses of insulin. She attempted to kill four others but failed.
Wettlaufer is serving a life sentence in prison.
Seven of the patents Wettlauder killed were residents of a long-term care facility in Woodstock, Ontario.
She was fired from that facility in 2014 after several medication mistakes but was then hired by the Meadow Park Care Home in London. Ontario, where she killed another resident.
In her confession, Wettlaufer said she used insulin to commit crimes because the medication was not tracked where she worked. She said she was also able to steal opioids without any consequences despite numerous reports about her poor job performance.
Her ability to work, even with 312 complaints about her behaviour, is highlighted in the report by Ontario appeals judge Eileen Gillese.
The commission led by Gillese determined that employers did not consider the possibility that staff members could or would deliberately harm patients.
The report says Wettlaufer was able to work because of systemic vulnerabilities in the long-term health care system, that the long-term care system is strained but not broken, and that the only reason the murders were discovered was because Wettlaufer confessed.
The main recommendation of the Gillese report is that long-term centres should adopt a hiring and screening process that includes robust background checks, examining gaps in employment, and learning why job candidates were terminated from their previous place of employment.
Andrea Silcox, the daughter of one of the victims, said she hopes the recommendations will directly address the oversight of Ontario's nursing homes.
"Just in hope that the Canadian government actually does stand up and take some of the recommendations that commissioner Gillese has written out in her report, and take them to heart, and actually do something about it," said Silcox.
Other recommendations include giving more funding to the industry, including grant money so facilities can strengthen security around medications.
The report also recommends implementing a searchable database for incidents, and limiting the supply of insulin in long-term care facilities.
With reporting from Annie DeMelt