Elizabeth Wettlaufer, a rogue nurse, made countless medication errors, routinely stole drugs to feed her addiction, murdered at least eight vulnerable patients and tried to kill a handful of others under her charge in long-term care homes.
Despite being an incompetent employee who racked up complaints, she never wanted for work, received positive letters of recommendation when employers wanted to be rid of her and, despite multiple red flags, never would have been caught had she not confessed to the killings. (Ms. Wettlaufer killed the patients, aged 75 to 96, by giving them overdoses of insulin, a drug that is commonly used in the long-term care setting.)
And it’s nobody’s fault.
Nobody’s damn fault.
There were no acts of “individual misconduct” by employers, supervisors, union reps, Ministry of Health inspectors, nursing regulatory bodies, coroners and so on.
The litany of screw-ups was due to “systemic vulnerabilities.”
All the failings that allowed murders and lord knows what other abuse to happen, were apparently not the failings of people – they were attributable to the dreaded, amorphous, anonymous, responsibility-free system.
That is the wimpy, all-too-Canadian conclusion of the two-year long, four-volume, 1,491-page Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System.
“Assigning blame to individuals or organizations is counterproductive,” according to Justice Eileen Gillese, the Ontario Court of Appeal judge who presided over the inquiry.
Systemic issues, we are told, are “best dealt with by encouraging people to go down a path where they can change the things that went wrong.”
Okay, so lest we hurt people’s feelings (or careers) by talking about what they failed to do in the past, let’s focus on what they could do better in the future.
The inquiry made 91 recommendations on what needs to be done to prevent similar tragedies in the future, including:
- Better training for administrators on how to screen, hire, manage and discipline staff;
- Bolstering the medication-administration system in long-term care homes;
- Expanding funding from the Ministry of Health and Long-Term Care;
- Conducting a study to determine adequate staffing levels in long-term care homes.
- Bolstering inspections, and giving priority to responding to “high-risk incidents” such as fatal medication errors;
- More clear reporting requirements for service providers and staff, both to the ministry and regulatory colleges and more robust investigations;
- Better death records, and more frequent autopsies of patients who die in long-term care;
- Building awareness of the “health-care serial-killer phenomenon”
We didn’t need a public inquiry to tell us that long-term care homes are grossly underfunded and understaffed.
Unfortunately, the inquiry didn’t make any specific recommendations on how to remedy this, and the province, in turn, promised nothing but to study the issue.
The people living in long-term care – 78,667 beds in 626 licensed homes in Ontario alone – are among the most frail and vulnerable in society. Almost two-thirds are living with dementia, and most have a multitude of chronic health problems.
Ensuring that patients are not murdered is important, obviously.
But also important, and far more relevant, is ensuring that every single patient has quality, hands-on care every day and every night.
In many institutions, that’s not happening now, to the point where families are fearful of placing their loved ones in long-term care.
The Registered Nurses’ Association of Ontario has proposed that there be mandated staffing ratios: 20 per cent registered nurses, 25 per cent registered practical nurses and 55 per cent personal support workers and, in addition, one nurse practitioner per 120 residents.
That would definitely mean better care, but it would also markedly increase the cost of care.
Those are the tough, bottom-line discussions we need to have.
Ultimately, it’s about the value we place on the quality of life of our elders.
Let’s be frank: Elizabeth Wettlaufer was not a sophisticated serial killer. Through her actions, she virtually begged to be found out.
The reason she was not caught was not solely because of the lack of checks and balances, and administrative/regulatory failures outlined in the report.
It was something more insidious: The people she killed didn’t much matter because they were old and sick.
What patients in the long-term care system need to fear is not individual killers, but a culture of indifference that allows inadequate and second-rate care to be accepted as the norm.
That is not going to change simply by throwing more money and more bodies into the current system.
One of Justice Gillese’s conclusions was that the “long-term care system is strained but not broken.”
But many parts of it are broken. Many people and institutions need to start taking responsibility for that – personal responsibility.
Our Morning Update and Evening Update newsletters are written by Globe editors, giving you a concise summary of the day’s most important headlines. Sign up today.