Sys­tem Fail­ure

How the nurs­ing home mur­der spree could have been pre­vented

ZOOMER Magazine - - CON­TENTS - By Wanda Mor­ris

Sys­tem Fail­ure How the nurs­ing home mur­der spree could have been pre­vented

FOR EIGHT YEARS, from 2007 to 2014, reg­is­tered nurse El­iz­a­beth Wet­t­laufer de­liv­ered toxic doses of in­sulin to pa­tients. She chose a dozen vic­tims to mur­der – four sur­vived; eight did not.

Re­peat­edly, in­di­vid­u­als and in­sti­tu­tions had op­por­tu­ni­ties to in­ter­vene. Re­peat­edly, they failed to do so. Dur­ing the four years Wet­t­laufer worked for Ca­res­sant Care Homes in Wood­stock, Ont., she was sus­pended four times for med­i­ca­tion er­rors be­fore fi­nally be­ing dis­missed. Shortly there­after that dis­missal, she was hired by Meadow Park in nearby Lon­don where she mur­dered her fi­nal vic­tim. From news re­ports, it ap­pears that Meadow Park was aware of Wet­t­laufer’s past med­i­ca­tion er­rors but de­cided to give her a sec­ond chance.

They weren’t the only ones giv­ing

Too of­ten, his­tory re­mem­bers the per­pe­tra­tor but for­gets the vic­tims. We re­mem­ber those killed in the nurs­ing home mur­ders. Mau­reen Pick­er­ing Gla­dys Mil­lard He­len Mathe­son Ar­pad Hor­vath James Sil­cox Mary Zu­raw­in­ski Mau­rice (Moe) Granat He­len Young

out sec­ond chances.

Wet­t­laufer is known to have con­fessed her mur­ders to a nurse’s aide, to a pas­tor and his wife, to a cou­ple of friends, to two for­mer lovers and to spon­sors help­ing her with her strug­gle with al­co­hol and drugs. While some claimed not to have be­lieved her con­fes­sions, oth­ers, in­clud­ing the pas­tor and his wife, de­cided she de­served an­other chance. That is ou­tra­geous! Who shields a mur­derer and puts other in­no­cent lives at risk?

For her crimes, Wet­t­laufer has been sen­tenced to life in prison where she must serve a min­i­mum of 25 years with­out el­i­gi­bil­ity for pa­role. Has jus­tice been done? Per­haps. But what about a sys­tem that de­spite re­peated warn­ings – and out­right con­fes­sions – al­lowed her to kill again and again.

CARP, to­gether with the Ad­vo­cacy Cen­tre for the El­derly, have de­manded a pub­lic in­quiry into the Wet­t­laufer case. To its credit, the On­tario Gov­ern­ment has agreed and is pro­ceed­ing with an or­der-in­coun­cil to ap­point a com­mis­sioner. But will it go far enough?

We have a sys­tem that should pro­tect our frail el­derly. It fea­tures manda­tory an­nual in­spec­tions, manda­tory re­port­ing of sus­pi­cious deaths, manda­tory re­port­ing of nurses who fail to care prop­erly for their pa­tients and manda­tory re­port­ing of known or sus­pected abuse. Yet all that was not enough. Re­peat­edly, in­sti­tu­tions and in- di­vid­u­als failed to act. On pa­per, there were mul­ti­ple checks and bal­ances to pro­tect long-term-care res­i­dents. In re­al­ity, Wet­t­laufer’s vic­tims were ex­posed and vul­ner­a­ble. Un­less the pub­lic in­quiry ex­plic­itly ad­dresses the roles of all who should have, but failed to pro­tect the vic­tims, it will fall short.

Wet­t­laufer was, of course, just the tip of the ice­berg. Homi­cides are, thank­fully, rare, but ev­ery year more than a thou­sand in­di­vid­u­als are vic­tims of res­i­dent-on-res­i­dent aggression in On­tario alone. One such in­di­vid­ual, James Acker, was beaten so se­verely by a fel­low res­i­dent he later died of his in­juries.

How can this be hap­pen­ing? I be­lieve Wet­t­laufer would have been stopped long be­fore her eighth mur­der if she’d at­tempted her crimes in a dif­fer­ent set­ting. I be­lieve some (not all) long-term-care homes are lit­tle more than ware­houses for the frail and el­derly, toxic en­vi­ron­ments where sup­port and care are pro­vided at the con­ve­nience of the staff rather than ac­cord­ing to the needs of the pa­tients. Too many fa­cil­i­ties have im­mense staff turnover and ram­pant sick time or em­ploy staff who are un­der-trained, un­der-cre­den­tialed and un­der-paid.

In­ves­ti­gate Wet­t­laufer – by all means. But don’t stop there. In­ves­ti­gate why thou­sands of res­i­dents have been hurt by other res­i­dents and why some care homes are such toxic places to work that com­pe­tent, qual­i­fied in­di­vid­u­als don’t ap­ply and homes are forced to hire sec­ond-, third- or even fourth-rate can­di­dates.

Wet­t­laufer’s ex­treme ac­tions might have been rare, but the sto­ries we re­peat­edly hear from our mem­bers and oth­ers tell us that abuse and ne­glect in long-term care are all too com­mon.

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