WOODSTOCK, Ont. – A public inquiry examining the case of a serial-killer nurse who preyed on elderly patients delivered its final report on Wednesday.
The report delved into the circumstances that allowed Elizabeth Wettlaufer to kill eight patients without drawing suspicion while she worked at several long-term care facilities and private homes for nearly a decade.
Had Wettlaufer not confessed and turned herself in to police, the report stated, her crimes would have gone undiscovered.
The report places the blame on systemic vulnerabilities, adding that no individual or organizational misconduct could have led to the undetected killings.
The 1,500 page, four-volume report brings with it 91 recommendations aimed at preventing similar crimes in the future.
The recommendations are built around four strategies: prevention, awareness, deterrence and detection.
More than a dozen recommendations work in conjunction with prevention, including one suggestion that calls for establishing a new unit to ensure long-term care homes are compliant and use the best practices, improve the skills of existing workers, and encourage the use of new technology in long-term care homes.
WATCH: Vulnerabilities in long-term health-care system must be exposed: Commissioner of Wettlaufer inquiry
The awareness strategy hopes to shed light on what the report calls “the healthcare serial killer phenomenon.” This strategy would share the province’s information on healthcare serial killers with other jurisdictions, including the rest of the country, the United States and other international agencies.
The focus on deterrence calls for increasing the number of registered staff in long-term care homes, strengthening medication management and improving incident analysis strategies for possible insulin overdoses.
This strategy also seeks to have the Ministry of Long-term Care establish a grant program that could provide long-term care homes with up to $200,000 to help fund required infrastructure changes. The Ministry is also being called on table to legislature for a study that would look into whether long-term care homes have adequate staffing levels.
The bulk of the final strategy, detection, revolves around an overhaul of the Institutional Patient Death Record (IPDR). Under its redesign, the new IPDR aims to contain more thorough information surrounding a resident’s death and would strengthen the processes that go into the decision to not conduct a death investigation.
IPDRs would also have to be submitted electronically in order to allow investigators to track trends, spikes or clusters in deaths – data that may have been helpful in detecting Wettlaufer’s crimes.
If a resident dies in hospital, an IPDR must be submitted if the death occurred within 30 days of a transfer out of a long-term care home. The recommendation also calls for increased communication between the Ministry and the College of Nurses of Ontario.
WATCH: Killer nurse Elizabeth Wettlaufer serving time at Quebec psychiatric hospital (Oct 3, 2018)
Wettlaufer is serving a life sentence after pleading guilty in 2017 to killing eight patients with insulin overdoses and attempting to kill four others.
Seven of the patients she killed were residents of Caressant Care in Woodstock, Ont., the community where the report is being released today.
Wettlaufer 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 resident.
She told lawyers with the inquiry that she chose insulin to commit her crimes because it wasn’t tracked where she worked.
The judge, police and prosecutor in her criminal case all said she wouldn’t have been caught without her confession.
The public inquiry’s commissioner, Eileen Gillese, has said the probe is about healing “broken trust” in the long-term care system.