The regulatory body for Ontario nurses decided against launching a formal investigation into the firing of Elizabeth Wettlaufer, later revealed to be a serial killer, because it heard from Ms. Wettlaufer's former boss that the nurse was upfront about making medication errors and had no "underlying" issues.
But the long-term care facility in Woodstock, Ont., that dismissed Ms. Wettlaufer in 2014 sent the College of Nurses of Ontario a summary of 10 workplace violations that suggest the home had serious concerns about her performance at the time she was fired, according to correspondence obtained by The Globe and Mail.
None of the incidents described in the documents involve Ms. Wettlaufer trying to harm patients on purpose.
Ms. Wettlaufer, 50, pleaded guilty in June to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault, all for injecting elderly patients with overdoses of insulin.
One of those murders and two of the attempted murders took place after Ms. Wettlaufer was fired on March 31, 2014, from Caressant Care in Woodstock, the nursing home where she murdered seven of her eight victims.
The details of Ms. Wettlaufer's 2014 firing, and of a 1995 incident in which she was found "dazed and disoriented" at work after ingesting stolen anti-anxiety medication, emerged during a disciplinary hearing for Ms. Wettlaufer on Tuesday.
A chair, table and nameplate waited for Ms. Wettlaufer in the college's hearing room, but she did not attend.
The ex-nurse, now serving a life sentence in prison, was found guilty of professional misconduct and formally stripped of her licence.
"This is the most egregious example of abuse and disgraceful conduct that this panel has ever considered," said Grace Fox, chair of the five-member disciplinary panel.
One of the lingering questions in the case is how Ms. Wettlaufer managed to commit her crimes undetected over 11 years under four different employers.
A public inquiry into the case has been announced.
The correspondence obtained by The Globe on Tuesday includes a letter to the college from Carol Hepting, vice-president of operations at Caressant Care, dated Oct. 14, 2016 – after Caressant Care learned that Ms. Wettlaufer had confessed to murder and was under police investigation.
"Based on information that has recently come to our attention we wish to restate our position that the above-named nurse [Ms. Wettlaufer] is unfit to safely practice nursing," the letter reads.
But Mark Sandler, a lawyer for the college, said nobody at Caressant Care ever told the college's investigators verbally or in writing that Ms. Wettlaufer was not fit to work safely as a nurse.
"This is Caressant taking a position in writing after everyone knows that Ms. Wettlaufer is guilty of serious criminality," Mr. Sandler said in an interview with The Globe.
"It does not accurately reflect what it was that Caressant sent to the college in 2014, nor does it accurately reflect what [Caressant's] director of nursing said to the college when we followed up."
A spokesman for Caressant Care declined to comment on Tuesday.
Caressant's letter of October, 2016, refers to its termination report to the college, dated April 17, 2014, which explained that Ms. Wettlaufer had been fired for giving insulin meant for another patient to a resident who was also diabetic.
The report, also obtained by The Globe, details nine other incidents over two and a half years that culminated in Ms. Wettlaufer's dismissal, including four violations for which she was suspended.
The incidents included leaving medication on a dining-room table; failing to sign out a narcotic she gave to a patient; administering eye drops incorrectly to a patient; and failing to properly treat a patient whose blood-sugar levels had dropped, among others.
The report does not say that Caressant considered Ms. Wettlaufer unfit to safely continue working as a nurse.
At Tuesday's hearing, Megan Shortreed, the college's counsel, said that Caressant Care's director of nursing told college staff in 2014 that "there was no underlying issue or concern with the member [Ms. Wettlaufer,] that was she always upfront about her errors, never denied the incidents and took ownership of her errors."
That is why the college concluded further investigation was not warranted, Mr. Sandler said.
The college requires that employers who fire a nurse for professional misconduct or incompetence notify the regulatory body within 30 days.
Mr. Sandler said the college receives about 1,300 such notices every year.
The disciplinary panel also heard on Tuesday that Ms. Wettlaufer was fired from an unnamed hospital in late 1995 after she stole some Lorazepam, a benzodiazepine used to treat anxiety.
According to a police affidavit filed last year in court, Ms. Wettlaufer was living in Geraldton in northwest Ontario in 1995 and was working at the local district hospital.
The college investigated and eventually determined that she should be allowed to keep her licence provided she agree to stay drug- and alcohol-free, remain under the care of a doctor and addictions specialists and submit urine samples, among other conditions.
The college based that decision on reports from two medical examiners, one a psychiatrist, the other a substance-abuse specialist, both of whom concluded Ms. Wettlaufer was fit to practise.