Elizabeth Wettlaufer, Canada’s only known health care serial killer, wouldn’t have been caught if she hadn’t confessed.
That was one of the principal findings of a commission of inquiry into the deaths of seniors under Wettlaufer’s care in long-term care homes in southwestern Ontario.
Over the course of nine years ending in 2016, Wettlaufer, a registered nurse, killed eight and attempted to kill others by injecting her victims with insulin.
They were not mercy killings, Commissioner Eileen E. Gillese wrote in her final report, released Wednesday. Wettlaufer killed “for her own gratification and for no other reason.”
WATCH: Wettlaufer inquiry commissioner Eileen E. Gillese releases her findings
The commissioner said that in the report she had “no hesitation” in finding that Wettlaufer’s offences wouldn’t have been discovered if she hadn’t turned herself in.
The finding is important, she wrote, because without systemic changes — the report contained 91 recommendations — similar tragedies could go undetected in the Canadian healthcare system.
Here’s how the commissioner drew that conclusion.
No one raised suspicions
Wettlaufer is serving a life sentence with no chance of parole for 25 years after her 2017 conviction on eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault.
Wettlaufer was the catalyst for her own prosecution. In 2016, she quit her job and checked into Toronto’s Centre for Addiction and Mental Health. She admitted to a psychiatrist, and later police, that she had killed and hurt patients.
WATCH: Wettlaufer report cites systemic failures in long-term care
Until that point, she hadn’t even been under investigation, despite having hurt or killed 14 seniors.
“The evidence showed that no one suspected that Wettlaufer was intentionally harming those under her care — not the residents or their families, not those who worked alongside Wettlaufer, and not those who managed and supervised her,” the commissioner wrote.
Further, Wettlaufer also faced indirect oversight from the Ministry of Health and Long-Term Care, which inspected the facilities she worked at, and as well as from coroners who investigated some of the seniors’ deaths.
In 2014, she had been fired from Caressant Care in Woodstock, Ont., in part for medication errors.
WATCH: What do we gain from an inquiry into Elizabeth Wettlaufer?
The College of Nurses of Ontario kept Wettlaufer’s termination notice on file, but, the licensing body took no action to suggest it had “serious concerns” about the care Wettlaufer had provided, Gillese found.
At a press conference on Wednesday, Gillese said that one of the clear lessons of the inquiry is that crimes can go undetected when the possibility that healthcare workers might cause intentional harm goes unrecognized.
“We have to improve awareness that this is an actual threat,” she said.
One of the report’s recommendations is that the government of Ontario ensure that a strategic plan is in place to build awareness of the healthcare serial killer phenomenon.
Insulin made her crimes difficult to detect
Wettlaufer herself told lawyers with the inquiry that she chose insulin because it wouldn’t be missed — the drug isn’t tracked as closely as, say, a narcotic.
But her use of the drug also aided in Wetlauffer’s crimes going undetected from a scientific standpoint, the commissioner concluded.
Even in cases where an autopsy is performed, it’s not easy to identify if someone has died due to an insulin overdose, according to the province’s chief forensic pathologist.
Dr. Michael Pollanen, who testified at the inquiry and the criminal trial, gave several reasons for this.
For one, there’s no post-mortem test for low blood sugar (hypoglycemia), and the symptoms are associated with other conditions. There are also “serious practical challenges” to identifying that hypoglycemia, if present, was caused by insulin, Gillese wrote.
WATCH: Killer nurse Elizabeth Wettlaufer serving time at Quebec psychiatric hospital
When someone dies, it’s also difficult to distinguish natural and synthetic insulin in the body, the report stated.
As well, deaths from an insulin overdose could take days to occur.
The judge concurred
Another reason why Gillese found that Wettlaufer’s confession was the only means by which she would have been caught is that the judge who presided over the criminal case drew the same conclusion.
In his sentencing decision on June 26, 2017, Justice Bruce Thomas acknowledged what he called Wettlaufer’s “free run” on her nine-year killing spree, with no oversight or even an inkling she had been killing patients.
“Without her confessions, I am convinced these offences would never have been brought to justice,” he said, calling Wettlaufer a “shadow of death that passed over them (the victims) on the night shift where she supervised.”
— With files from The Canadian Press