Key recommendations from report,

A public inquiry examining the case of Elizabeth Wettlaufer, a serial-killer nurse who preyed on elderly patients in her care, has issued a report aimed at preventing such crimes in the future. Here are some key recommendations from the 91 listed in the report:

The government of Ontario should ensure that a strategic plan is in place to build awareness of the health-care serialkiller phenomenon.

The Ministry of Health and Long-Term Care should create new, permanent funding for long-term-care homes for training, education and professional development for those caring for residents.

The ministry should expand the parameters of the funding it gives homes for nursing and personal care to allow them to spend it on a broader spectrum of staff, including pharmacists and pharmacy technicians.

It should create a three-year program under which homes can apply for grants of $50,000 to $200,000, based on their size, to improve visibility and tracking of medication.

The ministry should refine its performance assessment program for long-term-care facilities to better identify those struggling to provide a safe and secure environment.

It should conduct a study to determine adequate levels of registered nursing staff in longterm-care facilities and table the findings by July 31, 2020. If the study shows a need for additional staffing to ensure residents’ safety, homes should receive more government funding.

Long-term-care homes should analyze medicationrelated incidents and adverse drug events through a framework that includes screening for possible intentional harm.

Homes should document and track the use of glucagon, a hormone that raises a person's blood sugar, to identify patterns and trends.

Facilities should require that directors of nursing conduct unannounced spot checks on evening and night shifts, including weekends.

Homes must maintain a complete discipline history for each employee so management can easily review it while making discipline decisions.

The Office of the Chief Coroner and the Ontario Forensic Pathology Service should replace the current form submitted when a long-term-care patient dies with a redesigned, evidence-based death record that includes whether aspects of the resident's decline or death were inconsistent with the expected medical trajectory.

They should also develop protocols on the involvement of forensic pathologists in death investigations of long-term-care residents, as well as a standardized protocol for autopsies performed on the elderly.

The College of Nurses of Ontario should revise its policies and procedures to reflect the possibility that a health-care provider might intentionally harm those in their care.