An experienced appeal court judge will head a sweeping public inquiry into systemic issues at Ontario’s long-term care homes that may have contributed to the murders of eight seniors at the hands of a longtime nurse.
The province announced Tuesday that Ontario Court of Appeal Justice Eileen Gillese will have a broad mandate to review policies, procedures and oversight of long-term care homes and will file a report to the Attorney General by July 31, 2019.
The inquiry was triggered by the case of Elizabeth Wettlaufer, who pleaded guilty in early June to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault.
Her crimes, which took place over the course of nearly a decade in three Ontario long term-care facilities and a private home, have made Wettlaufer one of Canada’s most prolific serial killers.
In all those cases, Wettlaufer — who is currently serving a life sentence with no chance for parole for 25 years — deliberately overdosed her patients with insulin.
The judge who presided over her criminal case said the 50-year-old never would have been caught if she didn’t confess to the killings while at a psychiatric hospital in Toronto last September. Court heard she had access to insulin and covered her tracks when using the medication to harm her patients.
“My team and I will do our utmost to determine how these events could occur and to make recommendations so that the tragedies of the past are not repeated in the future,” Gillese said in a statement.
The inquiry was announced by Ontario’s Attorney General and the Minister of Health and Long-Term Care on the same day Wettlaufer pleaded guilty.
On Tuesday, the province provided more details on the probe.
Gillese’s appointment as the inquiry’s commissioner takes effect immediately, the province said. Gillese has been an appeal court judge since 2002 and is a former dean of Western University’s law school.
The inquiry’s final report will include recommendations that will improve the safety and well being of senior residents, the province said.
Doris Grinspun, the CEO of the Registered Nurses Association of Ontario, applauded the broad range given to the inquiry’s commissioner.
“My colleagues are crying for an in-depth look at nursing homes to ensure that resources are put in place so that they can deliver the care that they want to deliver,” she said.
One of the areas likely to be scrutinized by the public inquiry is the role Ontario’s nursing regulator played in the Wettlaufer case.
Some details of the College of Nurses of Ontario’s involvement came under the spotlight at a disciplinary hearing last week, where the regulator found Wettlaufer guilty of professional misconduct and revoked her certification.
The college knew Wettlaufer was fired from the Caressant Care nursing home in Woodstock, Ont., for a medication error in 2014, but she continued to work — and harm patients — until she resigned as a nurse in September 2016.
Caressant Care told the college about the firing, but the college said it decided not to conduct a formal investigation after interviewing the facility’s nursing director, who the college said identified no underlying issues with Wettlaufer.
Caressant Care, however, said in a statement a day after the disciplinary hearing that it had no records indicating its leadership told the college Wettlaufer didn’t have any underlying issues.
The home said it filed a 20-page report outlining its concerns to the college about Wettlaufer and never heard back from the regulator until Wettlaufer resigned as a nurse more than two years later. It said Wettlaufer was fired after making ten workplace violations over two-and-a-half years, with three violations that led to suspensions.
A lawyer representing the college said the regulatory body was satisfied at the time that Wettlaufer had owned up to the errors at Caressant Care and that there was no evidence of intent to harm her patients.
Mark Sandler also said that documentation that supports the college’s position will be provided to the public inquiry.
By not doing an official investigation, the Caressant Care firing remained private, which meant the public, and other nursing employers, didn’t know about the termination.