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The Honourable Eileen Gillese releases her report on long term care on July 31 2019.

Fred Lum/The Globe and Mail

A failure to imagine that a trusted nurse could become a serial killer within the Ontario health-care system allowed Elizabeth Wettlaufer’s crimes to go undetected, a public inquiry has concluded.

Pointing fingers at anyone other than Ms. Wettlaufer – who was sentenced to life in prison in 2017 after she pleaded guilty to murdering eight of her nursing-home patients – would not fix the “systemic vulnerabilities” that let Ms. Wettlaufer clandestinely inject seniors with lethal doses of insulin, Commissioner Eileen Gillese said.

As a result, Justice Gillese, a member of the Court of Appeal for Ontario, elected not to make any findings of “individual misconduct” against the players in the province’s long-term care system who might have prevented Ms. Wettlaufer’s murders.

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“It appears that no one in the long-term care system conceived of the possibility that a health-care provider would intentionally harm those within their care,” Justice Gillese said as she unveiled 91 recommendations designed to protect residents of Ontario’s 626 nursing homes.

“If you don’t conceive of the possibility, you don’t look for it and you don’t take steps to prevent it,” she said.

Justice Gillese made 91 recommendations aimed at preventing another health-care serial killer from preying on vulnerable residents inside the province’s 626 long-term care homes.

Geoff Robins/The Canadian Press

Ms. Wettlaufer, now 52, confessed in the fall of 2016 to murdering eight of her patients and trying to kill several others over nine years while working for four different employers, including the Caressant Care nursing home in Woodstock and Meadow Park nursing home in London.

She pleaded guilty to eight counts of first-degree murder, four of attempted murder and two of aggravated assault.

She confessed to killing a ninth patient after the inquiry began, but police elected not to pursue charges in that case.

The long-term care system failed to prevent eight murders. The Wettlaufer inquiry failed by not holding anyone accountable

Children of Wettlaufer’s nursing-home murder victims hope final public inquiry report finds solace, makes a difference

Justice Gillese unveiled her nearly 1,500-page, four-volume final report at a hotel in Woodstock, Ont., packed with relatives and friends of Ms. Wettlaufer’s victims.

Daniel Silcox, whose father, James Silcox, 84, was the first to be killed by Ms. Wettlaufer in 2007, said he understood why the commissioner stopped short of assigning blame.

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But he added that some of the players in the system were negligent, including a local coroner who declined to investigate the deaths of seniors who Ms. Wettlaufer later confessed to murdering.

“If anybody had done the autopsy on my father, it could potentially have saved seven other people,” Mr. Silcox said. “My heart breaks because of that.”

Justice Gillese’s report found that Ontario’s long-term care system is “strained, but not broken,” which she said makes it possible to improve the law governing nursing homes without tossing it aside and starting over.

To that end, her recommendations focused on strengthening medication management, employee training, record-keeping, communication and staffing at nursing homes and related institutions, including the coroner’s office and the regulatory college that disciplines nurses.

Many of the recommendations would cost “little or nothing to implement,” the report said, but for those changes that require more funding, “the cost is proportional to the serious threat that health-care serial killers present in the long-term care system.”

Long-Term Care Minister Merrilee Fullerton, one of four cabinet ministers from the Ford government who met with the families of the victims in Woodstock on Wednesday, promised “immediate action" on the recommendations, but declined to commit to any specific timelines or dollar figures.

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She did, however, answer Justice Gillese’s calls for the government to submit a follow-up report next summer and to continue paying for counselling for relatives of the victims for two years.

Susan Horvath, the daughter of Arpad Horvath, Sr., Ms. Wettlaufer’s eighth murder victim, praised the public inquiry’s final report but said she was disappointed that the government did not promise a specific amount of new funding for nursing homes right away.

“They have the power to do it," Ms. Horvath said. "The question is, do they want to?”

The public inquiry’s report does not put a total price tag on the proposed changes.

Among its recommendations is a call for the government to spend the next year studying whether to increase the number of “registered staff” required for day, evening and night shifts at nursing homes.

Right now, only one registered nurse is required to be on site, no matter the size of the home or time of day, and there is no minimum requirement for registered practical nurses.

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Justice Gillese unveiled the four-volume final report in Woodstock, the Southwestern Ontario city where Elizabeth Wettlaufer injected seven of her eight victims with lethal doses of insulin.

Fred Lum/The Globe and Mail

The report also suggested that the ministry create a new three-year grant program that would allow homes to apply for between $50,000 and $200,000, depending on their size, to improve the security of their medication rooms by adding glass windows, security cameras and bar-code systems.

Other recommendations include: requiring nursing homes to adopt a hiring and screening process that includes robust reference checks; forcing directors of nursing to conduct unannounced spot checks on nights and weekends; requiring homes to keep a complete discipline history for all staff; creating a new official death record that would be submitted electronically to the coroner’s office; and beefing up government inspections, including looking more closely at homes with higher-than-expected mortality rates.

The Long-Term Care Homes Public Inquiry examined more than 42,000 pages of documents and heard testimony from 50 witnesses over 39 days, most of it at a courthouse in St. Thomas, Ont.

During that time, the inquiry heard how several players in the system missed opportunities to catch Ms. Wettlaufer, a nurse with a disturbing track record of personal drug abuse, sloppy practices and conflicts with her colleagues and bosses.

As the report points out, she was driven to kill by her own unhappiness and rage, and was in no way a “mercy killer.”

The seniors that Ms. Wettlaufer was convicted of killing were Mr. Silcox, Mr. Horvath, Maurice Granat, Gladys Millard, Helen Matheson, Mary Zurawinski, Helen Young and Maureen Pickering. The patients she injected with overdoses of insulin but didn’t kill were Sandra Towler, Clotilde Adriano, Albina deMedeiros, Wayne Hedges, Michael Priddle and Beverly Bertram.

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Ms. Bertram, the only remaining survivor today, sat in a wheelchair in the front row as Justice Gillese presented her report.

Ms. Wettlaufer attempted to kill Ms. Bertram in 2016 with an overdose of insulin delivered as the nurse cared for her at her home in Ingersoll, Ont.

“She doesn’t deserve my pity,” Ms. Bertram said of Ms. Wettlaufer, "but I’m sorry for her.”

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