Judge heads in­quiry into long-term care homes

Broader man­date called for by crit­ics

The Hamilton Spectator - - FRONT PAGE - LIAM CASEY

TORONTO — 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 says On­tario Court of Ap­peal Jus­tice Eileen Gillese will have a broad man­date to re­view poli­cies, pro­ce­dures and over­sight of longterm care homes and will 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, made her 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 case said the 50-year-old never would have been caught if she hadn’t con­fessed 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.

The in­quiry was an­nounced by On­tario’s At­tor­ney Gen­eral and the Min­is­ter of Health and LongTerm Care on the same day Wet­t­laufer pleaded guilty.

Gillese’s ap­point­ment as the in­quiry’s com­mis­sioner takes ef­fect im­me­di­ately. It will in­clude rec­om­men­da­tions that will im­prove the safety and well be­ing of se­nior res­i­dents, the prov­ince said.

The gov­ern­ment has launched a web­site for the in­quiry, which states that in­ves­tiga­tive work has al­ready be­gun and pub­lic hear­ings will be held in 2018.

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.”

The On­tario Health Coali­tion, a pub­lic health ad­vo­cacy group, is con­cerned about its du­ra­tion.

“The gov­ern­ment’s man­date for the in­quiry gives it two years to con­duct its work, push­ing the fi­nal re­port and rec­om­men­da­tions un­til well af­ter the next elec­tion and me­dia in­ter­est has died,” said ex­ec­u­tive di­rec­tor Na­talie Mehra. “This is too long. It means that rec­om­men­da­tions will not be forged and acted upon for years.”

On­tario NDP Leader and Hamil­ton Cen­tre MPP An­drea Hor­wath is blast­ing the gov­ern­ing Lib­er­als for what she calls a missed chance to ad­dress many se­ri­ous is­sues with long-term care by hav­ing an in­quiry only look into the Wet­t­laufer mur­ders.

Min­istry of At­tor­ney Gen­eral spokesper­son Em­i­lie Smith con­firmed the in­quiry man­date is “to in­quire into … con­tribut­ing fac­tors which led to the of­fences com­mit­ted by a par­tic­u­lar per­son.”

It means cases like Hamil­ton’s James Acker, who was at­tacked and se­verely beaten in his sleep by an­other res­i­dent on his floor at St. Joseph’s Villa in Fe­bru­ary and later died, won’t be looked into.

“I think the gov­ern­ment missed an op­por­tu­nity to do the right thing,” said Hor­wath. “We be­lieve this is an op­por­tu­nity to have a hard look at what’s hap­pen­ing in long-term care. It’s def­i­nitely in cri­sis,” she added. “Our con­cern is it (the in­quiry) is not look­ing into the safety of res­i­dents and staff and other iden­ti­fied prob­lems.”

While she agrees the Wet­t­laufer mur­ders need to be looked into, so do other se­ri­ous prob­lems: “The hor­ror sto­ries be­ing shared by loved ones are too com­mon … we need a full in­ves­ti­ga­tion.”

The in­quiry needs a broader scope, 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 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 the nurse.

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.

Jus­tice Eileen Gillese will lead the in­de­pen­dent pub­lic in­quiry.


The in­quiry will look at poli­cies, pro­ce­dures and over­sight of long-term care homes af­ter Eliz­a­beth Wet­t­laufer ad­mit­ted killing se­niors in her care.

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