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The “Long-Term Care Homes Public Inquiry” Report: Addressing Pervasive Issues in Elder Care in the Aftermath of the Wettlaufer Murders

There is hope that some positive changes can be made to a broken system, following the senseless tragedy of Elizabeth Wettlaufer’s murder of eight elderly nursing-home residents. With today’s release of the much-anticipated “Long-Term Care Homes Public Inquiry”, a public inquiry report into Ms. Wettlaufer’s murder spree, the Province of Ontario now has 91 judicial recommendations on how to correct deficiencies in its long-term care system so that such heinous crimes can be avoided in the future and so nursing homes can provide better care and oversight to vulnerable patients.

Ms. Wettlaufer, a registered nurse, killed eight patients in two separate Ontario nursing homes between 2006 and 2016. She murdered her victims by intentionally administering overdoses of insulin. Her monstrous crimes went entirely undetected during that period, and Ms. Wettlaufer continued to be employed by long-term care facilities in this province, until she decided to voluntarily turn herself in and confess in 2016.  Ms. Wettlaufer was given a life sentence in 2017 with no chance of parole for 25 years, after she pleaded guilty to eight counts of first-degree murder; four counts of attempted murder; and two counts of aggravated assault.

A public inquiry into Ms. Wettlaufer’s crimes was launched in August of 2017, in order to shed light on how Ms. Wettlaufer’s murders went undetected for so long and to make recommendations on how to fix a damaged long-term care system in Ontario that provides care for nearly 80,000 residents at 626 care homes across the province.

Justice Eileen Gillese, of the Ontario Court of Appeal, presided over the inquiry and released her findings today, Wednesday July 31, 2019, in Woodstock, Ontario, which is home to the Caressant Care long-term care facility where Ms. Wettlaufer killed seven residents. The inquiry consisted of almost 40 days of public courtroom hearings and written submissions which illuminated an under-funded, short-staffed and badly neglected long-term care system that allowed for Ms. Wettlaufer’s crimes to take place.

Justice Gillese’s four-volume report contains 91 recommendations that call for, among other actions: increased government funding for the training and education of nurses, intensive ministry oversight of nursing homes, and large ministry grants to individual care homes for the necessary infrastructure to secure and monitor medication supplies.

Justice Gillese cited “systemic vulnerabilities” in the long-term care system that permitted Ms. Wettlaufer to continue to prey upon her victims, and the report states that “systemic issues require a systemic response”. Justice Gillese’s recommendations placed a strong emphasis on raising public awareness in regards to the vulnerability of care home patients. The report advocates for a concerted province-wide campaign to raise awareness of the possibility that health-care providers (the very people who are supposed to help patients) may intentionally harm patients in care facilities.

The report, which Justice Gillese dedicated to Ms. Wettlaufer’s victims and their families, makes recommendations to the government of Ontario (particularly the Ministry of Long-Term Care and Ministry of Health), the College of Nurses, and individual care facilities with the ultimate goal of filling the gaps in a “strained” system so that crimes like Wettlaufer’s cannot be repeated.

While Justice Gillese’s report and its recommendations are not binding on the Province, the Health Minister, Christine Elliott, and the Long-Term Care Minister, Merrillee Fullerton, were on-hand to receive Justice Gillese’s findings in Woodstock, and have said that additional government funding will be dedicated to implementing the report’s recommendations.

The Wettlaufer case is one glaring example of how the long-term care system in Ontario has been neglected, and how the vulnerable patients within that system are put at significant risk as a result. Hopefully, Justice Gillese’s recommendations are taken seriously and implemented by the Province of Ontario and care facilities so that deficiencies within the system are addressed and some positive change can be salvaged from these unspeakable tragedies.



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