System Failure

How the nursing home murder spree could have been prevented

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.