Elizabeth Wettlaufer is one of the most prolific serial killers in Canadian history.
While working as a nurse, she killed at least eight nursing-home residents and attempted to kill at least six others.
Yet, we know surprisingly little about her methods, her motives and the institutional and regulatory failings that allowed her to get away with murder for almost a decade.
Most chilling of all, had Ms. Wettlaufer not confessed, we would be none the wiser.
Police and the justice system have done their duty. Ms. Wettlaufer pleaded guilty to eight counts of first-degree murder, four of attempted murder and two counts of aggravated assault, and was sentenced to life in prison with no chance of parole for at least 25 years.
But now the important work must begin – to determine how frail, elderly, vulnerable patients such as those in her care can be better protected and cared for.
The Ontario government, to its credit, announced a public inquiry as soon as the verdict was in. But it has yet to specify its scope and mandate.
Let's be clear: The inquiry must not be about one rogue nurse, but a sweeping, unflinching look into the state of long-term care.
Ontario alone has more than 630 long-term care homes, with 78,000 residents at any given time.
The population is among the most frail and vulnerable there is: Their lives, and the quality of their lives, literally depend on sound regulation.
If the evil deeds of an unsophisticated, drug-addicted killer can go undetected for nearly 10 years, one shudders to think what other forms of abuse and neglect are going unnoticed.
If a nurse who, time and time again demonstrated that she was incompetent, was able to hold a job that conferred great responsibility, one has to question the competence of the regulatory body that oversees nursing.
Ms. Wettlaufer began practising as a registered nurse in 1995, but trouble does not seem to have begun until 2007, when her personal life went off the rails and she killed her first victim with an overdose of insulin.
Most of the time, she worked the night shift at Caressant Care Woodstock Nursing Home, where she was repeatedly suspended for poor performance, but not fired until 2014, because of medication errors.
Ms. Wettlaufer found work quickly at Meadow Park Nursing Home in London, Ont., where she killed again. She subsequently worked for three more nursing homes and a home-care agency before her arrest in the fall of 2016.
Along the way, Ms. Wettlaufer struggled with drug addiction (drugs she stole from the medication cart for which she was responsible). She also mentioned that she was killing or hurting patients to at least 10 people, none of whom told police.
It was not until Ms. Wettlaufer sought treatment at the Centre for Addiction and Mental Health in Toronto that health professionals there reported the crimes to police, as is their legal responsibility.
The College of Nurses of Ontario, despite numerous disciplinary reports, did not suspend Ms. Wettlaufer's nursing license until after she had confessed to the murders. The college has a hearing planned for July 25, a bit late to help any patient.
Clearly, an inquiry has plenty to examine related to Ms. Wettlaufer, but it needs to look beyond that to the state of care more generally.
Anecdotes about interminable waits for admission, inadequate staffing, neglectful care leaving residents in soiled incontinence pads and with pressure ulcers, resident-on-resident violence and excessive use of drugs, such as antipsychotics, are too numerous to ignore.
But this should not be an exercise in persecution of care homes and care providers, who are all too often in an untenable situation – too many residents to care for, too few trained staff and too little money because neither the state nor individuals want to pay more.
An inquiry should shed light not only on technical and systemic failings, but on our culture, which sees the elderly as burdensome and disposable.
Ms. Wettlaufer is a monster. But never has a serial killer garnered so little media attention.
There is no doubt why. The people she murdered were old and institutionalized.
That is why she could have got away with it. That is also why the care is too often sub-par and we know it.
That is the most monstrous reality of all.