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Elizabeth Wettlaufer, the nurse who murdered eight long-term-care patients in southwestern Ontario over nearly a decade, is a monster. To read about her crimes is to be confronted with extraordinary evil.

But in the early days of Ontario’s public inquiry into her serial killings, she has also emerged as something more banal but only slightly less troubling: a dangerously bad nurse.

No one ever caught Ms. Wettlaufer murdering patients: She confessed in 2016, nearly a decade after first taking a life.

However, the inquiry has already discovered much about Ms. Wettlaufer’s repeated professional misconduct, which was detected and then swept under the rug. These details point to a long-term-care system as vulnerable to understaffing, timid management, union power and lax professional bodies as to serial killers.

Consider that Ms. Wettlaufer was fired from her first nursing job in 1995 for stealing and using hospital drugs, but that this information was hidden from future employers as a result of a union grievance.

Later, while working at a home in Woodstock, Ont., she was reprimanded and suspended – but not fired – for a litany of mistreatment and abuse, including neglecting to give a needy patient oxygen for three nights and puncturing another patient’s hematoma with scissors not known to be sterile.

Despite all this, and in part because it was so hard to recruit nurses, Ms. Wettlaufer was often the most senior employee on night shifts, which is where she did much of her killing, overdosing patients with insulin.

When she finally was fired, for mishandling medications, the home in Woodstock wrote her a letter of recommendation and sealed her file.

Murder is rare in Ontario’s long-term care homes, but abuse of residents by staff is not: A CBC investigation found there were 2,198 such incidents reported in 2016, up nearly 150 per cent from 2011.

As our population ages, these facilities are increasingly common places for Canadians to live out their final years. To ensure dignity and decent care for seniors, we must do far more than stymie the next serial killer in their midst.

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