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 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.
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.
Seven of the patients Wettlaufer killed were residents of Caressant Care in Woodstock, Ont., the community where the report was released Wednesday. She was fired from Caressant Care in 2014 after multiple medication errors and was then hired by the Meadow Park care home in London, Ont., where she killed a 75-year-old.
She went on to inject a patient at a Paris, Ont., home and one in home care with insulin. Both survived.
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.
Paola Loriggio , The Canadian Press