Killer Nurse: How the sys­tem failed

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El­iz­a­beth Wet­t­laufer mur­dered eight se­niors in On­tario nurs­ing homes over a pe­riod of nine years. Fol­low­ing the pub­lic in­quiry, Alex Roslin ex­plores how bud­get cuts, poor staffing and ageism in the long-term care sys­tem cre­ated an en­vi­ron­ment for the se­rial killer to run amok

EL­IZ­A­BETH WET­T­LAUFER made an odd dis­cov­ery when she was hos­pi­tal­ized in the psy­chi­atric ward. Think­ing about mur­der made her anger go away. Sort of. Wet­t­laufer had a lot of anger – so much that she could barely con­cen­trate. She was also quite de­pressed and had been di­ag­nosed with ob­ses­sive-com­pul­sive be­hav­iour.

She was in the hos­pi­tal be­cause she had tried to kill her­self with an over­dose of med­i­ca­tions. When that failed, she had stolen clean­ing fluid from a hos­pi­tal with the idea of drink­ing it to com­mit sui­cide. But then, she re­al­ized some­thing.

“If I thought about killing some­body while I was talk­ing to other peo­ple, I could talk nor­mally to them,” as Wet­t­laufer later ex­plained. “But in this part of my mind, I was think­ing about some­body I’d like to kill ... It was like I had two heads.”

But whom to kill? Wet­t­laufer thought about killing her psy­chia- trist, a nurse, a co-worker. Then, after she got out of the hos­pi­tal, she thought of the per­fect tar­get – se­niors.

Wet­t­laufer had by this point been hired as a nurse at Ca­res­sant Care, a for-profit long-term care home in Wood­stock, Ont., 140 kilo­me­tres west of Toronto. She se­ri­ously dis­liked her job from the start. Her work­load on the af­ter­noon and night shifts was un­real. Due to a dire short­age of nurses in long-term care, she of­ten had to do dou­ble shifts, stay­ing awake up to 24 hours.

At night, she was re­spon­si­ble for up to 163 res­i­dents – giv­ing med­i­ca­tion, chang­ing dress­ings, putting on lo­tion, keep­ing up with pa­per­work, re­spond­ing to emer­gen­cies, su­per­vis­ing sup­port work­ers. A more ap­pro­pri­ate staffing level would have been one nurse for each 10 or 20 res­i­dents, given the heavy needs of res­i­dents, Ca­res­sant Care staff would later say. Many res­i­dents had de- men­tia or were ex­tremely frail and needed ex­tra care. Yet, a nurse could de­vote as lit­tle as 4.5 min­utes to each res­i­dent per shift.

The stress sent Wet­t­laufer over the edge. “It got to the point, like fairly quickly, that I was find­ing it hard to han­dle things emo­tion­ally,” she later told lawyers work­ing for the Longterm Care Homes Pub­lic In­quiry that the prov­ince es­tab­lished to in­ves­ti­gate how Wet­t­laufer got away with mur­der­ing eight se­niors in long-term care homes and hurt­ing six oth­ers from 2007 to 2016.

The in­quiry, which started hold­ing hear­ings last June and is ex­pected to is­sue a re­port in July, has re­vealed in shock­ing de­tail how var­i­ous in­sti­tu­tions failed to pro­tect se­niors from Wet­t­laufer. She can­didly told about 10 peo­ple she had killed se­niors, but no one did any­thing. She re­mained a nurse de­spite mak­ing dozens of med­i­ca­tion er­rors and other work mis­takes, for which she was most

com­monly not pun­ished. Her poor record wasn’t dis­closed to sub­se­quent em­ploy­ers and, be­cause of the nurs­ing short­age, em­ploy­ers kept giv­ing her an­other chance.

Wet­t­laufer was only caught be­cause she turned her­self in to po­lice – ap­par­ently the only health-care se­rial killer ever to do so any­where in the world. She is now serv­ing eight con­cur­rent life terms with no chance of pa­role for 25 years. Her frank con­fes­sions to po­lice and in­quiry lawyers give im­por­tant in­sights into the fright­en­ing – and grow­ing – phe­nom­e­non of health-care work­ers who mur­der those in their care. As pop­u­la­tions age, while re­sources don’t keep pace, these killers are in­creas­ingly tar­get­ing se­niors.

AT FIRST, Wet­t­laufer tried to sup­press her tur­moil of emo­tions by recit­ing or singing Bible verses she was raised on in her Bap­tist fam­ily. But as Wet­t­laufer’s stress shot up, she started to feel what she called a “red surge” and hear a voice in her head. She thought it was God. It urged her to mur­der.

She made her first at­tempt a few weeks after start­ing work at Ca­res­sant Care in June 2007. Her tar­get was Clotilde Adri­ano, 87, who had di­a­betes. “This thought came into my head: just give her too much in­sulin and see what hap­pens. So I did,” she told in­quiry lawyers.

In­sulin is the mur­der weapon of choice for se­rial killers who work in health care. A mas­sive in­jec­tion of in­sulin makes a per­son’s blood sugar level fall dan­ger­ously. In­sulin isn’t gen­er­ally mon­i­tored in nurs­ing homes, so no one no­tices if some dis­ap­pears. (In­sulin can of­ten be bought in phar­ma­cies with­out a pre­scrip­tion.) In­sulin also dis­si­pates quickly from the body and can’t be de­tected un­less a blood sam­ple is col­lected within about 48 hours of death. Since there were so few staff, es­pe­cially at night, Wet­t­laufer could of­ten act un­no­ticed. If ques­tioned, she’d ex­plain it was a vi­ta­min in­jec­tion.

After Wet­t­laufer in­jected Adri­ano, the woman’s blood sugar dropped, but staff no­ticed and gave her juice to re­vive her. She sur­vived. Wet­t­laufer then tried to kill Adri­ano’s sis­terin-law, Al­bina deMedeiros, who was 91 and also had di­a­betes, but again failed.

Wet­t­laufer went on­line to re­search in­sulin and how oth­ers had used it for mur­der. She was bet­ter pre­pared for her next tar­get, Se­cond World War vet­eran James Sil­cox, 84, who had di­a­betes, Alzheimer’s and other ail­ments. He couldn’t walk and was of­ten con­fused, ask­ing fre­quently for his wife – the per­fect vic­tim to Wet­t­laufer’s mind. “Ev­ery pa­tient I ever picked had some de­men­tia,” she told in­quiry lawyers. “They couldn’t re­port or if they re­ported they wouldn’t be be­lieved.”

The night of Aug. 11, 2007, Wet­t­laufer was work­ing a dou­ble shift from 3 p.m. to 7 a.m. At around 9:30 p.m., she took in­sulin from a stor­age room and in­jected Sil­cox with a mas­sive dose. He didn’t die right away. For hours, Wet­t­laufer heard Sil­cox shout­ing in his room, seem­ingly call­ing to his wife. “I love you. I love you,” he re­peated. At 3:55 a.m., Sil­cox was found with no vi­tal signs, cold and blue.

Wet­t­laufer said on a form that the death was “sud­den and un­ex­pected.” This trig­gered a visit from a lo­cal coro­ner, Dr. Wil­liam Ge­orge. On ex­am­in­ing the body and med­i­cal records, Ge­orge pro­nounced the cause of death to be “com­pli­ca­tions of [a] frac­tured right hip.” (Sil­cox had bro­ken his hip in a fall a few days be­fore.) Ge­orge de­clined to do an au­topsy and noted that he had spo­ken with mem­bers of Sil­cox’s fam­ily, who “had no fur­ther con­cerns.”

In fact, Sil­cox’s fam­ily says Ge­orge didn’t speak with them at the time and that they did have con­cerns. Daugh­ter An­drea Sil­cox was sleep­ing when she got a call from one of her sis­ters say­ing their fa­ther had died. An­drea re­mem­bers sit­ting up in bed and re­spond­ing in dis­be­lief: “What, why would Dad be dead?” De­spite his health prob­lems, he was still phys­i­cally vig­or­ous, An­drea told Zoomer. “My dad had a will to live.”

An­drea’s sis­ter Dianne Craw­ford said the coro­ner was “very dis­mis­sive” when she called him sev­eral weeks after their fa­ther’s death, ac­cord­ing to Craw­ford’s af­fi­davit to the in­quiry. “I got the im­pres­sion that the coro­ner felt that my call was un­war­ranted as my fa­ther was an el­derly man and there was noth­ing un­usual about his death,” Craw­ford said.

Ge­orge, for his part, told the in­quiry that he usu­ally spoke with fam­ily mem­bers but didn’t keep his notes from this case to con­firm he did so. He said he “would never have been dis­mis­sive” to Craw­ford and stood by his de­ci­sion not to do an au­topsy, in­sist­ing he hadn’t missed any­thing in his ex­am­i­na­tion.

An­drea Sil­cox is dumb­founded by Ge­orge’s re­sponse. “If they had an au­topsy [right away], they would have found an over­abun­dance of in­sulin in my dad’s sys­tem.

How many peo­ple would have been saved?” she asked. Sil­cox is su­ing Ca­res­sant Care and Wet­t­laufer over her fa­ther’s mur­der. She says her mother was deeply af­fected by the news of Wet­t­laufer’s crime and died shortly after. “I know it was a bro­ken heart,” An­drea Sil­cox says.

THE NO­TION that deaths in long-term care aren’t un­ex­pected or wor­thy of closer in­ves­ti­ga­tion came up again and again at the in­quiry. The idea was ap­par­ently drilled into the heads of nurses – Wet­t­laufer in­cluded. “We were told, ‘No, if they’re in a nurs­ing home, they need care. Their death isn’t un­ex­pected,’” Wet­t­laufer told in­quiry lawyers.

The at­ti­tude is hor­ri­fy­ing to Laura Tam­blyn Watts, chief pub­lic pol­icy of­fi­cer at CARP, Canada’s largest se­niors’ as­so­ci­a­tion and ZoomerMe­dia’s af­fil­i­ate ad­vo­cacy or­ga­ni­za­tion. “It’s an as­ton­ish­ing state­ment. Older peo­ple have ev­ery right to a safe home en­vi­ron­ment. Imag­ine that state­ment be­ing made about any other group of peo­ple.”

In fact, the coro­ner’s at­ti­tude came amid moves to dras­ti­cally cur­tail in­ves­ti­ga­tions into se­nior deaths. Coroners used to in­ves­ti­gate ev­ery death in On­tario long-term care homes, but that changed in 1995 when provin­cial bud­get cuts re­duced it to ev­ery 10th death at a fa­cil­ity. Even these lim­ited in­ves­ti­ga­tions were slashed again in 2013 to save more money. The rule was changed to re­quire an in­ves­ti­ga­tion only if a death was deemed “sud­den and un­ex­pected.” But even that pal­try re­quire­ment is ig­nored in prac­tice, it would seem, if long-term care deaths are never con­sid­ered un­ex­pected.

The de­cline in coro­ner in­ves­ti­ga­tions has come at the same time as long-term care homes strug­gle to pro­vide for se­niors with high needs, such as those with de­men­tia. The por­tion of high-needs res­i­dents in long-term care more than dou­bled from 2007 to 2015 (from 35 per cent to 74 per cent), while the num­ber of nurses hasn’t kept pace and their pay has stayed flat.

Chronic un­der­staffing in longterm care has been a well-known prob­lem since 2001, thanks to five ear­lier re­ports on the lack of nurses in the sec­tor. In­ad­e­quate staffing and heavy work­loads were, fur­ther­more, blamed for abuse of se­niors in the homes. What’s worse, the prov­ince also lacks enough in­spec­tors to over­see the homes and de­tect abuses, in­spec­tors told the Wet­t­laufer in­quiry. “Given the re­sources that I have now, I can’t keep up,” provin­cial in­spec­tion man­ager Karin Fairchild tes­ti­fied.

The prob­lems go be­yond On­tario. In Que­bec, long-term care res­i­dents launched a $500-mil­lion class-ac­tion law­suit last sum­mer com­plain­ing about “de­plorable and shame­ful” con­di­tions. Among the com­plaints: staff give se­niors an­tipsy­chotic drugs in an “abu­sive man­ner” to se­date them in or­der to re­duce work­load; ex­ces­sively use phys­i­cal re­straints on res­i­dents; give poor-qual­ity food to lower costs; force res­i­dents to wear a di­a­per even if they aren’t in­con­ti­nent and don’t change di­a­pers for those who are; and de­mand bribes for ser­vices that res­i­dents have a right to.

This trou­bling en­vi­ron­ment seems to be in­creas­ingly at­tract­ing se­rial killers. Nurs­ing pro­fes­sor Beatrice Crofts Yorker of Cal­i­for­nia State Univer­sity, Los An­ge­les, stud­ied 131 health-care work­ers pros­e­cuted for se­rial mur­der world­wide. In her ini­tial study in 2006, 20 per cent of the vic­tims were long-term care res­i­dents. By 2018, that por­tion jumped to 36 per cent, ac­cord­ing to a re­port that Crofts Yorker pre­pared for the Wet­t­laufer in­quiry. The over­all num­ber of health-care se­rial killers is also sky­rock­et­ing, from five prose­cu­tions in 25 coun­tries in the 1970s to 16 in the 1980s, 25 in the 1990s and 60 in the 2000s.

Crofts Yorker’s re­port in­cluded the same ad­vice as the five ear­lier re­ports on long-term care in On­tario: hire more nurses. More staff could de­ter se­rial killing and im­prove care for all. She cited re­search that found each pa­tient added to a nurse’s work­load re­sults in a seven per cent in­crease in a pa­tient’s chance of dy­ing.

AFTER WET­T­LAUFER’S first mur­der, a di­a­bol­i­cal laugh­ter erupted in her belly “like a cack­ling from the pit of hell,” she later told po­lice. She won­dered if the devil or God was talk­ing to her. She went home, did some ex­er­cise, played some com­puter games and tried to for­get what she had done.

But the work stress, voices and anger didn’t go away. She started to steal hy­dro­mor­phone, a pow­er­ful opi­oid pain medicine, from the nurs­ing home and use it once or twice a week, of­ten while at work. She was soon drink­ing heav­ily,

El­iz­a­beth Wet­t­laufer is es­corted from the provin­cial court­house in Wood­stock, Ont., on June 1, 2017.

An­drea Sil­cox, daugh­ter of vic­tim Jane Sil­cox, is hugged by Laura Jack­son, friend of vic­tim Mau­rice Granat, out­side the court­house in Wood­stock, Ont. on Jan. 13, 2017.

Ar­pad Hor­vath Jr. sits out­side the El­gin County Court House in St. Thomas, Ont., on June 5, 2018, dur­ing a break in pro­ceed­ings of On­tario’s Long-Term Care Homes Pub­lic In­quiry. His fa­ther was one of Wet­t­laufer’s vic­tims.

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