Elizabeth Wettlaufer quit her job at Meadow Park Long-Term Care in London, Ont., the day after a large amount of narcotics went missing.

She spent the weekend in hospital after overdosing, a public inquiry heard.

Wettlaufer abruptly resigned from her job as a nurse at Meadow Park in late September 2014, saying she had an illness that prevented her from working as a nurse.

That was less than a month after she'd killed Arpad Horvath, 75, at that nursing home.

For the first time, the Wettlaufer inquiry has heard from a former employee of Meadow Park, the last place Wettlaufer is known to have killed someone in her care. She went on to injure others at subsequent jobs.

Testifying at the public inquiry at the Elgin County courthouse in St. Thomas, Ont., on Tuesday was Heather Nicholas, who was the director of care at Meadow Park.

Nicholas hired Wettlaufer and also accepted her resignation. She cried near the end of her testimony, saying she felt terrible that Wettlaufer killed Horvath while working at the home.

An email outlining how drugs were stolen at Meadow Park Long-Term Care, which casts suspicion on Elizabeth Wettlaufer. (Kate Dubinski/CBC News) "I just feel bad for the family. I just feel really awful about what happened," she said.

Missing narcotics led to police probe

On Sept. 26, 2014, a pharmacist delivered four bags of medication to Meadow Park. A registered nurse took the medication, which included narcotics.

The day before, Wettlaufer had handed her boss a note saying she was resigning. Sept. 26 was her last shift. It was a Friday.

Later, Wettlaufer told Nicholas that she had a drug and alcohol problem and that she'd spent that weekend in hospital after overdosing.

In early October, the narcotics were discovered missing and managers at Meadow Park suspected Wettlaufer. But they didn't report her to the Ontario College of Nurses because she'd already resigned and said she was getting treatment for an illness, Nicholas said.

The incident was reported to the Ministry of Health and Long-Term Care.

Nicholas said she thought maybe Wettlaufer would self-report to her profession's regulatory body, but didn't think Meadow Park had a responsibility to report the addiction and suspicion that Wettlaufer stole drugs.

Alex Van Kralingen, the lawyer for one group of families, pushed Nicholas on the issue.

"You knew there was an issue … an addiction issue, but you didn't report her to the college?" he said.

"No, I knew she had resigned, she was going to go for treatment. She didn't elaborate and I didn't ask."

Wettlaufer went on to work at a temp agency for nurses, Lifeguard HomeCare. They placed her at Telfer Place in Paris, Ont., where she tried to kill Sandra Towler, 77.

Wettlaufer eventually confessed to killing eight people and harming six others by injecting them with massive amounts of insulin.

Speaking outside the courthouse, Van Kralingen questioned Nicholas's assumption that Wettlaufer would report herself to the college.

"I think it's an unsatisfying answer on many levels," he said. "First, I don't think it properly accounts for the reality of someone who is addicted, [it's] unlikely they will self-report.

"Second, it disregards that home's obligation to the College of Nurses to report someone that is incapacitated ... Nobody did anything and I think we are starting to understand the frustrations of all of the families involved that the reporting systems that are in place that are legally required, none of them were followed."

Perfect score on med test

When she was thinking of hiring Wettlaufer, in April 2014, Nicholas said she relied on three references that called Wettlaufer compassionate and professional.

But the two references from the Caressant Care home in Woodstock, Ont., said Wettlaufer had some personality conflicts with managers and that she'd made a medication error.

Wettlaufer said she'd been dismissed because of a medication error, but assured Nicholas that she'd be cleared after a union investigation.

Nicholas made her take a medication test offered on the Ontario College of Nurses. Wettlaufer got a perfect score.

Later, she brought Nicholas a letter from her boss at Caressant Care, stating she was a "good problem solver with strong communication skills."

That letter was part of a deal reached on Wettlaufer's behalf by the Ontario Nurses' Association. Wettlaufer's termination was marked as a resignation and she also got $2,000.

Nicholas later said during cross-examination that Meadow Park did not conduct any spot checks or otherwise monitor Wettlaufer's insulin administration during her time there.

Documents not disclosed

Last week,the Ontario Nurses Association announced it had not disclosed documents related to Wettlaufer's firing from Caressant Care for medication errors to the commission.

Those documents detail the settlement negotiations between the union and Caressant Care management.

The Long-Term Care Homes Public Inquiry was established on Aug. 1, 2017 after Wettlaufer was sentenced to eight concurrent life terms. It began hearings on June 5, and is examining how Wettlaufer's crimes went undetected for so long.

Her killing spree began in 2007 and continued until 2016, when she finally confessed to a psychiatrist and a social worker. Until then, her employers, police and Ontario's licensing body for nurses had no idea eight patients had been murdered and six more poisoned with injections of massive doses of insulin.

The inquiry is being heard at the Elgin County courthouse and is scheduled to last until September.