“Systematic vulnerabilities” allowed disgraced nurse Elizabeth Wettlaufer to keep killing her senior patients and if it wasn’t for a confession, she wouldn’t have been caught, a public inquiry has concluded.

According to the new inquiry report, which was compiled from 10 weeks of testimony, Wettlaufer only received warnings instead of suspensions for her numerous medical errors. Commissioner of the Public Inquiry Eileen Gillese made the revelations on Wednesday.

Wettlaufer is serving a life sentence after she injected eight people with lethal levels of insulin and attempted to kill four others, while she was employed at Caressant Care long-term care facility in Woodstock, Ont. and the Meadow Park care home in London, Ont.

In 2014, she was fired from Caressant Care after multiple medication errors, but was hired by the London facility.

The four-volume report also stressed that “systematic vulnerabilities” in Ontario’s long-term care system allowed this to happen.

Jane Meadus, staff lawyer and the institutional advocate with the Advocacy Centre for the Elderly, agreed and told CTV News Kitchener, “it doesn't look that good if someone isn't being disciplined properly in those situations.”

According to Wettlauffer’s own testimony, "if there was a way that the insulin was counted, she would not have been able to do what she did without getting caught."

Gillese stressed 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."


Caressant Care‘s former director of nursing testified during the inquiry that cameras were supposed to be installed in the medication room. But they never were.

The inquiry also uncovered that there was a lack of communication between front-line workers, administrators, the College of Nurses of Ontario and the province.

"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," Gillese said.

The report outlined 91 recommendations which included the province giving more funding to the industry and long-term centres to build a more robust screening and hiring process.

Other recommendations for Ontario’s Ministry of Health and Long-Term Care included:

  • Granting money so homes can strengthen security around medication rooms, install glass doors and windows and hire staff pharmacist.
  • Building a universal reporting system for local health integration networks to adopt, which will include a searchable database for incidents.
  • Requiring insulin in homes to only be in limited supply.
  • Create a three-year plan through which facilities can apply for a grants of $50,000 to $200,000 to improve oversight of the administration of drugs.
  • Directors of nursing at facilities should conduct unannounced spot checks on evening and night shifts, including weekends.
  • Homes must maintain a complete discipline history for each employee

Staff and administrators of the long-term care system need to deal with the “widespread lack of trust,” Gillese said during the news conference.

“These are tragedies that of substantial public interest” she said, adding damage done to tarnish people’s trust in the long-term care system couldn’t be understated.

Gillese said "fundamental changes must be made -- changes that are directed at preventing, deterring, and detecting wrongdoing of the sort that Wettlaufer committed."

Daniel Silcox, whose father James was Wettlaufer’s first victim back in 2007, said that among the recommendations, there was one glaring omission.

“Nowhere have I seen a structure of an ombudsman's office where if there is an issue with any long-term care facility, that you can pick up the phone and phone the ombudsman and have some action," he said.

Caressant Care Nursing and Retirement Homes President and Owner Jim Lavelle thanked Gillese and her team for their “hard work and dedication” in providing “thoughtful, practical recommendations that can improve the long-term care system.”

“We also look forward to working with our stakeholders, health care partners and government to address the recommendations outlined in the report so that we can, as a system, restore public confidence in long-term care,” he said in a statement.


In a statement the commissioner said, “if Ontario is to be measured on how we care for our vulnerable members, then seize the opportunity presented in this report to become the acknowledged national leaders in caring for those in the long-term care system.”

Gillese also agreed with the report’s assessment that the system was strained but not broken.

The commission suggested the government report back in a year on the steps it took to address the recommendations. This would include the province conducting a study to determine how many registered employees are required on each shift to ensure proper staffing levels.

Marissa Lennox, director of policy and government relations at the Canadian Association for Retired Persons felt this step was “one of the recommendations (Ontario) could implement fairly quickly.”

“We know long-term care homes are chronically understaffed,” she told CTV’s Your Morning, explaining that in Ontario, long-term care homes only need to have one registered nurse on staff.

“Indeed, that’s how Elizabeth Wettlaufer was able to get away with a lot of her crimes. She was responsible for 90-plus people at one time,” Lennox explained. “How could one individual truly care for the needs … of 90 people?”

Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, hopes the province will take the report’s recommendations seriously.

“Staffing is critical if we’re going to improve the lives of residents and honour those lives tragically lost and the memories of their families,” she told CTV News Channel.

Ontario’s Minister of Long-Term Care Merrilee Fullerton told reporters on Wednesday that the government is open to providing long-term care facilities with the money the inquiry has recommended.

"We are committed to taking action and providing new funding," she said. "We will do a comprehensive review over the coming weeks.

But even if Ontario followed the recommendations, Gillese admitted 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.

With a report from CTV News Kitchener and with files from The Canadian Press