A public inquiry into Elizabeth Wettlaufer’s nursing-home murders could have assigned blame far and wide and at every level of the system, from the individual homes right up to the provincial government.

That’s because the long-term care home system, the most regulated industry in Ontario, never did catch Wettlaufer. The nurse’s decade-long ability to murder frail and vulnerable residents by injecting them with overdoses of insulin ended only when she decided, unprompted, to turn herself in and confess.

But Justice Eileen Gillese, who led the inquiry, rightly skipped the blame game and went straight to the heart of the matter: Making sure those failures are never be repeated by anyone else.

Now, with her 1,500-page report as a guide, the real work begins to ensure that Ontario’s 626 long-term care homes, where more than 78,000 residents live, are made better because of this tragedy.

The report’s 91 recommendations include increased training and education for long-term care home staff, more robust hiring and screening practices, less use of fill-in agency staff and government grants to improve how medication is secured and monitored in homes.

But surely one of the most important recommendations — and one that is most dependent on political factors — is the one calling on Premier Doug Ford’s government to produce a study within the next year “to determine adequate levels of registered staff in long-term care homes.”

Any objective study is certain to recommend increasing staff levels, from personal support workers to nurses, and following through on that will require more provincial funding.

That homes are badly understaffed, especially given the increasingly complex care nursing home residents need, came through loud and clear during the inquiry’s public testimony phase.

No one knew Wettlaufer was murdering patients but plenty of people knew she was a troubled nurse with a terrible record of patient care and medication errors. And yet she had no trouble finding work in the long-term care sector, at least in part because too few others were available or willing to do the job.

The Ford government must act so that frail and vulnerable residents are not only better protected from the possibility of a future healthcare serial killer, but better cared for on a daily basis.

That the government dispatched no fewer than four cabinet ministers to Woodstock, Ont., for the report’s release suggests it understands that.

Long-Term Care Minister Merrilee Fullerton said the province is committed to a “government-wide approach” to addressing the recommendations and “part of that plan will include providing new funding.”

That’s an excellent start. Though, of course, she wasn’t specific about how much new money or what it will pay for, and that will matter a great deal.

The challenge for this government will be staying the course when the money comes due. Ford’s administration has pumped up the provincial deficit and fears of it to such heights that it makes spending money seem like a failure of government rather than a proper and necessary response to public need.

The inquiry did not put a dollar figure on the implementation of its recommendations and much of the cost will ultimately come down to that all-important report on staffing levels.

Gillese was also careful to warn against an unnecessarily disruptive overhaul of the long-term care system.

“Although the long-term care system is strained, it is not broken,” she said. The existing regulatory regime “provides a solid foundation” to address the problems.

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That means there’s no excuse for the Ford government to delay concrete improvement by claiming the whole system needs to be revamped, as it has already done to terrible effect on other files, including autism.

The government should start immediately on many of the 91 recommendations, especially the study to determine staffing levels.

Changes designed to prevent another healthcare serial killer also provide a path to improve the quality of life in these homes. That sounds less dramatic, but it’s needed every bit as much.

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