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When the final report of the public inquiry into Elizabeth Wettlaufer’s nursing-home murders is released on Wednesday, Daniel Silcox is hoping to find some solace in its pages.

His father, James Silcox, an 84-year-old veteran of the Second World War, was the first patient the former Ontario nurse killed with a lethal dose of insulin in 2007.

Ms. Wettlaufer went on to murder seven others before she confessed in 2016.

“I don’t want my father’s death to have been for naught,” Mr. Silcox said by phone from his home in Kawartha Lakes, east of Toronto. “I want to think that part of his legacy is, in some small way, helping to improve this long-term-care industry, which is totally broken.”

The Long-Term Care Homes Public Inquiry, as it is officially known, was called in 2017 to figure out how Ms. Wettlaufer’s crimes went undetected and to make recommendations for improving a system that cares for more than 78,000 residents at 626 homes across the province.

Copies of a report by the Honourable Eileen Gillese into long term care facilities, on July 31, 2019.Fred Lum/The Globe and Mail

Ontario Court of Appeal Justice Eileen Gillese, who presided over the inquiry, will release her recommendations in Woodstock, Ont., not far from the Caressant Care location where Ms. Wettlaufer, now 52, killed seven of her eight victims.

Ms. Wettlaufer was sentenced to life in prison with no chance of parole for 25 years after pleading guilty to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault, all for injecting the vulnerable dementia patients in her care with overdoses of insulin.

Justice Gillese’s recommendations will not be binding, but the provincial government is expected to take them seriously. Four senior cabinet ministers, including Health Minister Christine Elliott, are scheduled to be in Woodstock for the report’s release.

Elizabeth Wettlaufer was sentenced to life in prison with no chance of parole for 25 years.Dave Chidley/The Canadian Press

Through written submissions and almost 40 days of public hearings at a courthouse in St. Thomas, Ont., last year, the inquiry heard over and over how various players missed the chance to stop Ms. Wettlaufer.

The testimony also painted a disturbing picture of an underfunded long-term-care system struggling to attract qualified nurses to care for patients with increasingly complex health problems such as severe dementia.

“We have to fund the system so we can encourage people to go work in long-term care,” lawyer Jane Meadus said, who represented an association of nursing-home residents’ councils during the inquiry.

“Anything to do with the elderly seems to be second class. That’s what we are hoping some of this [report] will change. How do we change the mentality?”

Ms. Wettlaufer’s work history was littered with red flags. She was fired in 1995 from her first job at a hospital in northwestern Ontario after she stole some anti-anxiety medication and was found dazed and disoriented at work.

Her dismissal was reported to the College of Nurses of Ontario, the regulatory body that oversees the profession, which investigated and eventually determined that she should be allowed to keep her licence.

In March of 2014, when Woodstock’s Caressant Care fired her for making a medication error that put a patient in danger, the College decided not to investigate further; her public record appeared unblemished until her confession.

Caressant Care, meanwhile, only reported to the College 10 of the 44 times Ms. Wettlaufer was warned or disciplined for bad behaviour before her dismissal.

The Ontario Nurses Union successfully grieved Ms. Wettlaufer’s 2014 firing, securing her a $2,000 payout and a recommendation letter saying she had resigned for personal reasons.

A local coroner in Woodstock declined to investigate the death of Ms. Wettlaufer’s seventh victim, Maureen Pickering, 79, despite an emergency room doctor and a nurse at Caressant Care raising concerns that her blood sugar had plummeted for no reason before her death.

Ms. Wettlaufer was hired soon after by the Meadow Park nursing home in London, where she killed her last victim, Arpad Horvath Sr., 75. She confessed to a ninth murder after the inquiry was called, but police elected not to pursue charges.

Susan Horvath (left) talks with Beverly Bertram between press conferences in Woodstock, Ont., on July 31, 2019.Fred Lum/The Globe and Mail

“This inquiry really opened up a huge, huge amount of negligence in all aspects of this entire [long-term care] industry,” Mr. Horvath’s daughter, Susan, said Tuesday.

She fears the inquiry won’t make a difference if the provincial government is unwilling to commit the necessary money to improve conditions in nursing homes.

“If they say, ‘Sorry, it’s not in our budget, but we’ll get to it’ … Then where are we?” she asked. “We’ll be back at square one.”

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