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Elizabeth Wettlaufer is escorted into the courthouse in Woodstock, Ontario on Friday, Jan. 13, 2017.

Elizabeth Wettlaufer, the former nurse already charged with the alleged murder of eight care-home residents in Southwestern Ontario, has been charged with attempting to murder four more patients by injecting them with insulin.

She is also charged with aggravated assault on two other people, also by allegedly plying them with insulin.

Investigators announced the additional charges just before the 49-year-old former nurse appeared Friday morning at the Ontario Court of Justice in Woodstock, Ont.

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While police have given no details about the way Ms. Wettlaufer is alleged to have committed her crimes, her use of insulin is confirmed in the updated charge sheet filed in court Friday.

A hormone that helps the body regulate blood-sugar levels, insulin has been cited in notorious past criminal trials, such as the case of the serial-killing British nurse Beverley Allitt, as the drug used to induce victims into a fatal coma.

Four of the newly identified victims lived at the Caressant Care home in Woodstock, where seven patients already have been alleged to have been drugged to death by Ms. Wettlaufer while she worked there between June, 2007, and March, 2014.

The new attempted-murder charges are alleged to have taken place from 2007 to August of last year, just a month before a tip led police to investigate Ms. Wettlaufer.

Police say Clotilde Adriano, 87, and Albina Demedeiros, 90, were victims of aggravated assault when they were injected with insulin between June and December, 2007.

Ms. Adriano and Ms. Demedeiros were sisters, a nephew confirmed.

The new charges also allege that Ms. Wettlaufer used insulin injections to try to murder two other Caressant residents: 57-year-old Wayne Hedges, between September and December, 2008, and Michael Priddle, 63, between January, 2008, and December, 2009.

The four latest victims at the Caressant facility – Ms. Adriano, Ms. Demedeiros, Mr. Hedges and Mr. Priddle – are no longer alive but police said the cause of their deaths is not attributed to Ms. Wettlaufer.

Ms. Wettlaufer is also charged with the attempted murder in September, 2015, of 77-year-old Sandra Towler at the Telfer Place Long Term Care facility in Paris, Ont., near Brantford.

Lastly, she is charged with the attempted murder in August, 2016, of Beverly Bertram, 68, at a private residence in Oxford County. (Ms. Wettlaufer's last two employers were agencies providing in-home care.)

Both cases are also alleged to have involved insulin injections.

The first eight alleged victims had been identified as James Silcox, 84; Maurice Granat, 84; Gladys Millard, 87; Helen Matheson, 95; Mary Zurawinski, 96; Helen Young, 90; Maureen Pickering, 78; and Arpad Horvath, 75.

Mr. Horvath lived at Meadow Park Long Term Care in London, Ont. The other seven lived at the Caressant Care home in Woodstock.

As the latest allegations were disclosed, relatives and friends of the victims were in Woodstock to witness Ms. Wettlaufer's court appearance on Friday.

A civil suit against the nursing homes that employed Ms. Wettlaufer is "inevitable," said Sandra Zisckind, a lawyer representing the Horvath family.

She said questions will be raised about whether those facilities took proper care of their residents.

"If you, as an owner, are not making sure that that person is taken care of, you're failing in your duties and you're negligent. That's how the law works," she said.

Laura Jackson, a close friend of another victim, Mr. Granat, echoed the concerns about nursing homes.

"This is not something that happened here and there. This is something that happened over a 10-year period in at least two nursing homes. Something needs to be done," Ms. Jackson said.

She recalled how, the night Mr. Granat died, she and a friend arrived to see their bedridden friend trying to fight off Ms. Wettlaufer, who was at his side.

Ms. Wettlaufer was curt to them and insisted on giving Mr. Granat an injection, Ms. Jackson recalled.

"The nursing home should be held responsible," she said.

The latest charges have also brought a spotlight on practices at the Telfer Place Long Term Care facility, where Ms. Wettlaufer is alleged to have tried to give a lethal insulin injection to Ms. Towler in 2015.

An executive for Revera, the home's parent company, said Ms. Wettlaufer worked at Telfer Place from February, 2015, to April, 2016. She was not on permanent staff but came as a temporary contract with a nursing agency.

"If there is an opportunity to learn from this situation, we will embrace it … we are all shocked and saddened," John Beaney, Revera's vice-president of operations for Ontario, said in an interview.

Inspection reports for Telfer Place show that on at least one occasion in 2015 and one in 2016, the carts that nurses use to deliver medications to residents were briefly left unattended and unlocked, which is against provincial rules.

Both incidents were caught during resident quality inspections on March 8, 2016, and March 13, 2015.

The 2016 inspection also found that during one shift on Dec. 28, 2015, a nurse in charge of the medication cart gave some doses of insulin to the home's executive director to administer to patients, even though the executive director was neither a nurse nor a doctor and was not allowed to give insulin.

Mr. Beaney said those incidents were "isolated oversights" and noted that, as a nurse, Ms. Wettlaufer had authorized access to the medication cart.

Before her arrest, Ms. Wettlaufer was a church-going woman who was also struggling with addiction and mental-health issues and had done two rehab stints.

A neighbour in Ms. Wettlaufer's apartment building told The Globe and Mail how she informed him casually last fall that she had been fired from two nursing jobs – once for stealing medication and another time for giving a patient the wrong medication while she was under the influence.

It was comments she made while being treated at Toronto's Centre for Addiction and Mental Health that led police to investigate her.

Within a month, a joint investigation by Woodstock Police Service, London Police Service and the Ontario Provincial Police led to Ms. Wettlaufer being charged in connection with eight deaths, including those of seven Caressant Care nursing-home residents who were allegedly killed between 2007 and 2014.

It was after a further review of medical records that the new charges were filed.

"Obviously, there's still a lot more questions than answers," an OPP spokesman, Sergeant David Rektor, told reporters Friday. "It's an ongoing investigation."

With files from Rick Cash and Kelly Grant in Toronto

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