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Inquiry to examine oversight, procedures that allowed Wettlaufer to murder patients

Elizabeth Wettlaufer pleaded guilty to eight counts of first-degree murder and four counts of attempted murder.


The public inquiry into the Elizabeth Wettlaufer case will look at the procedures and oversight mechanisms that allowed the former Ontario nurse to murder eight patients without anyone noticing until she confessed, the province announced Tuesday.

Justice Eileen Gillese of the Ontario Court of Appeal was appointed to lead the inquiry and the mandate of the commission will include not just the events leading to the eight killings but also "relevant policies, procedures, practices, and accountability and oversight mechanisms," said the government's order-in-council.

"We're glad that a commissioner has been appointed. We'd like to see it move forward quickly," said Patricia Matheson, daughter-in-law of Helen Matheson, a 95-year-old who was one of three women murdered in the fall of 2011 by Ms. Wettlaufer.

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Read more: Ex-nurse Elizabeth Wettlaufer sentenced to life in prison for Ontario nursing home murders

The Registered Nurses' Association of Ontario said it welcomed the inquiry's wide-ranging terms.

"We had insisted that it be a broad-based inquiry, that it look at absolutely every single aspect that might have contributed to these horrific killings," said Doris Grinspun, the association's chief executive officer.

Ms. Wettlaufer, 50, pleaded guilty in June to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault, all by injecting seniors with insulin.

Details of the case that have emerged in court suggest that she was a frustrated nurse who had an addiction problem and had trouble handling elderly patients with dementia. In her confession to police, she complained that she had to look after 32 residents during her night shifts at the Caressant Care facility in Woodstock, Ont.

Ms. Grinspun said that the inquiry needs to look at the funding and staffing requirements for Ontario nursing homes. She noted that, under the province's Long-Term Care Homes Act, only a minimum of one registered nurse is mandated at each nursing home. "This is absolutely shameful and archaic," she said.

Evidence in court has also shown that Ms. Wettlaufer had easy access to insulin that she used to murder her victims, and that she would not have been unmasked if she hadn't decided to confess her crimes while seeking psychiatric help in the fall of 2016.

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Furthermore, while she had been fired twice during her career, she was able to keep working as a registered nurse. She was sacked from a hospital in 1995 because she was dazed at work after ingesting a stolen tranquilizer. At Caressant, where she killed seven victims, she was dismissed in 2014 for a series of professional mistakes. However, the College of Nurses of Ontario didn't investigate that firing further because Ms. Wettlaufer owned up to those errors.

Ms. Matheson said the inquiry needs to look at "who dropped the ball."

She, like some other relatives of victims, have asked why insulin is so readily accessible to health professionals. In her confession, Ms. Wettlaufer had said she knew that insulin, which she used to overdose her victims without leaving traces, was neither secured nor strictly accounted for at Caressant, giving her quick access while she worked the night shifts.

"Changes need to happen," Ms. Matheson said.

In their impact statements read in court, many of the families of the victims had mentioned that the killings had shattered their trust in the health-care system.

"Of course we want answers for ourselves but it's also for the future," Ms. Matheson said. "If they don't change things, it's going to happen again."

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The inquiry's final report is due on July 31, 2019.

Video: Nursing body open to suggestions from Wettlaufer inquiry (The Canadian Press)
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About the Author
National reporter

Tu Thanh Ha is based in Toronto and writes frequently about judicial, political and security issues. He spent 12 years as a correspondent for the Globe and Mail in Montreal, reporting on Quebec politics, organized crime, terror suspects, space flights and native issues. More


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