A highly awaited report on safety and security in long-term care will focus on preventing serial killers from ever again preying undetected on victims in Ontario nursing homes.

The four-volume, 1,500 page report — to be released at noon Wednesday — “identifies the systemic vulnerabilities” that allowed registered nurse Elizabeth Wettlaufer to murder nine elderly people in her care by injecting them with insulin overdoses, says Mark Zigler, co-lead counsel for the provincial public inquiry into the killings.

Wettlaufer pleaded guilty in June 2017 to killing eight residents in two southwestern Ontario nursing homes, Caressant Care and Meadow Park London. She confessed to killing a ninth person after she began serving a life sentence.

Her murder spree would have gone unnoticed had she not confessed, unprompted, in September 2016.

“A lot of this is driven by the fact that no one ever thought this was possible,” Zigler said in an interview, referring to a serial killer operating in nursing homes. “It didn’t enter anyone’s mind, because they wouldn’t have known about her had she not confessed.”

Dozens of recommendations in the report are expected to call for change at all levels — from the security and protocols around accessing medication, to the oversight role of the College of Nurses and the Ministry of Long-Term Care, to the investigations conducted by coroners when a nursing home resident dies.

The inquiry’s commissioner — Justice Eileen Gillese of the Ontario Court of Appeal — will release the report at a hotel in Woodstock, Ont., home of the Caressant Care nursing facility where Wettlaufer killed seven of her victims. Families of the victims will be in attendance.

Ontario’s minister of long-term care, Merrilee Fullerton, is scheduled to speak after the report’s release. Accompanying her will be Health Minister Christine Elliott, Solicitor General Sylvia Jones and Ernie Hardeman, the minister of agriculture, food and rural affairs.

The heavy ministerial presence suggests a government prepared to take the report’s recommendations seriously, and confront significant skepticism.

The public inquiry heard from 50 witnesses in the summer of 2018, held dozens of further consultations with experts and long-term-care officials, and reviewed more than 42,000 documents containing some 400,000 pages.

“We want to make sure that, after all of this, this isn’t just another report that sits on a shelf,” says Vicki McKenna, president of the Ontario Nurses’ Association, the union representing 65,000 registered nurses and health-care professionals.

At least one daughter of a murder victim isn’t taking government action for granted.

“Are they really going to listen? Are they really going to do anything about it?” asks Andrea Silcox, whose father, James, was Wettlaufer’s first murder victim, in 2007. “I’ll believe it when I see it.”

Several previous reviews of long-term care have died of neglect, McKenna said in an interview, leaving long-identified problems unfixed, including the “frightening” low level of staff-to-resident ratios in nursing homes.

Jane Meadus, a lawyer who represented the Ontario Association of Residents’ Councils at the inquiry, says recommendations must focus on putting residents of nursing homes first.

“We really need to have people seen as people, not as widgets,” says Meadus, whose umbrella group represents residents in long-term-care homes.

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The inquiry found problems across the board, she adds, including a “major failure” in ministry oversight. Only after Wettlaufer confessed to her crimes did ministry inspectors go into Caressant Care and find a host of problems they had previously missed, resulting in an order that shut down admissions until they were fixed.

“Something like what Ms. Wettlaufer did is done in secret and in private, but it’s the culture that allows it to happen,” Meadus says.

Evidence at the inquiry, she adds, suggests an attitude of resignation, if not indifference, throughout the system: “We didn’t need to do this because everyone in long-term care is going to die.”

For example, coroners rarely, if ever, investigate deaths. “Everybody gets written down as dying of heart failure,” Meadus says.

The inquiry heard that even when an emergency room doctor and nurse at Caressant Care considered the death of a Wettlaufer victim suspicious — and asked the local coroner to investigate — the coroner did not.

Wettlaufer was a rogue nurse from the start. She was fired from her first job at a hospital in 1995 after being caught high on drugs, which she admitted to stealing on her overnight shift.

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The next two decades saw Wettlaufer disciplined dozens of times for medication errors, poor treatment of residents under her care, conflicts with co-workers, and generally shoddy work.

During her seven years at Caressant Care, until she was fired in March 2014 for a serious medication error, managers of the home noted more than 130 complaints against Wettlaufer from residents and co-workers in her employment file.

Yet after Caressant reported her firing to the College of Nurses — responsible for keeping the public safe from bad nurses — the college didn’t investigate her. Wettlaufer was left with a spotless public record and went on to kill two more people at the Meadow Park nursing home in London, Ont., and try to kill two more.

After firing her, Caressant managers agreed to a union demand and gave Wettlaufer a reference letter describing her as a “good problem solver.” McKenna called criticism of the union for the letter a “red herring.” The union has a legal obligation to represent members and it only has as much information about a nurse as employers provide.

“We weren’t representing a serial killer, we were representing a nurse with practice issues,” McKenna says.

Alex Van Kralingen, a lawyer representing families of four murder victims at the inquiry, says the report must recognize that “keeping residents of long-term-care facilities safe aligns entirely with the goals of providing high-quality care.”

It requires investment in more staffing to deal with the “physically and mentally taxing work” in nursing homes, he says. “More eyes on the (nursing home) floor means someone like Wettlaufer doesn’t have the time and space to get away with their crimes.”

Ministry officials who inspect nursing homes need more resources to ensure compliance and everyone needs to better understand their obligations under the law, Van Kralingen adds.

“Everything from skin care to nail care to the texture of food — how minced it should be — to the temperature of the homes is regulated,” Van Kralingen notes. “But there’s no point in having this highly regulated system if everyone involved at all levels, including management of the homes, don’t seem to understand their reporting obligations to the ministry or the College of Nurses.”

That’s an acute problem when many residents suffer dementia and don’t have the ability to advocate for themselves, he adds.

He notes that in the fall of 2014, a ministry inspector investigated missing opioids at the Meadow Park nursing home. Managers at the home told the inspector they suspected Wettlaufer. They also said Wettlaufer had revealed she had overdosed on drugs after the opioids went missing. Yet neither the inspector nor the managers reported Wettlaufer to the College of Nurses.

She assaulted more patients after leaving Meadow Park.

The public might never know whether Wettlaufer committed more crimes than those she confessed to.

Wettlaufer’s method of killing was a lethal injection of insulin, which can result in many hours of physical distress before the victim dies. During the inquiry, the Star revealed, in November 2018, that beyond those she admitted killing, another 248 nursing home residents died on her shifts, or within 24 hours of them. Ontario Provincial Police told the Star they were aware of those deaths, reviewed each medical file and didn’t lay any further charges.

Then came a CBC report revealing police knew Wettlaufer had confessed to killing a ninth victim as early as January 2018, but decided not to charge her. The public inquiry did not investigate that murder.

For Zigler, what’s clear is that Wettlaufer’s known crimes are shocking enough to hopefully result in real change for long-term-care residents.

“Maybe it takes something like that to shake up the system and create more confidence in it.”

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