Lessons Learned from the Long-Term Care Homes Public Inquiry
In September 2016, Elizabeth Wettlaufer quit her nursing job and checked herself into the Centre for Addiction and Mental health in Toronto where she subsequently confessed to harming and killing a number of people during the last nine years of her nursing practice. Wettlaufer’s choice method of harm was injecting her victims with insulin overdoses. The majority of these incidents took place in licenced, regulated long-term care homes in southwestern Ontario. Wettlaufer is, by all accounts, a healthcare serial killer.
In June 2017, Wettlaufer was convicted of eight counts of first-degree murder, four counts of attempted murder, and two counts of aggravated assault. She was sentenced to life in prison with no chance of parole for 25 years.
But the story did not end there. Wettlaufer’s crimes spurred public outrage and debate over the quality of Ontario’s long-term care system and the safety of those who rely on it. One of the many troubling questions that arose was: how could a registered nurse commit such serious crimes in regulated healthcare facilities for years without getting caught? To find answers and figure out how to prevent similar tragedies from occurring in the future, the Long-Term Care Homes Public Inquiry was launched (the “Public Inquiry”).
The Public Inquiry concluded on July 31, 2019 when the Honourable Eileen E. Gillese, Commissioner of the Public Inquiry, released her four-volume final Report of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the “Report”).
The Report makes three chief findings. First, the harmful acts committed by Elizabeth Wettlaufer would not have been discovered if not for her confession. Second, systemic vulnerabilities in the long-term care system are to blame for the harms that took place, rather than any individual or organization operating within the system. Third, the long-term care system is strained but has the robust regulatory regime and workforce needed to address existing systemic issues that have been exposed by the Public Inquiry.
Though I write at the risk of fear-mongering, that is by no means my intent. Indeed, I firmly believe that the large majority of healthcare providers uphold the ideals of patient or resident-centred care. The Report, in my view, is noteworthy for the bright light it shines on the potential for a nurse or other healthcare professional to intentionally harm those under their care. As astutely stated in the Report, “We can prevent, deter, and detect only matters of which we are aware” (volume 1, page 18).
It is prudent for residents or their substitute decision-makers to be on high alert for signs of abuse by staff in long-term care homes and issue complaints where appropriate. The Long-Term Care Homes Act , the statute which governs Ontario’s long-term care homes, contains several provisions concerning residents’ rights and the complaints process that can be of assistance. The takeaway is that anyone can be a potential advocate for a vulnerable resident of a long-term care home.
Arielle Di Iulio