The commission investigating the actions of serial killer nurse Elizabeth Wettlaufer and how Ontario's long-term care home system failed to detect her eight murders over a decade will present its report Wednesday.

The report examines how Wettlaufer, a nurse at several long-term care facilities in southwestern Ontario, was able to access lethal doses of insulin to kill her patients, to steal opioids to feed her own addiction and to continue being employed despite numerous reported flaws in her work.

Wettlaufer quit her nursing job in 2016, checked herself into a psychiatric hospital and confessed her crimes.

She had confessed to many people over the years but none reported her, saying they didn't believe her.

Wettlaufer pleaded guilty in 2017 to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault. She committed her crimes between 2007 and 2016, with most of the murders happening at Caressant Care in Woodstock, Ont., a city about 140 kilometres southwest of Toronto.

Wettlaufer, who is now 52, is serving eight concurrent life sentences, with no chance of parole for 25 years.

The inquiry knew that Wettlaufer made more confessions. Mark Zigler, the inquiry's lead co-counsel, issued the statement in February after CBC News reported she made more confessions to police in January 2018.

Systemic failures

The two-year Public Inquiry into the Safety and Security of Residents in the Long Term Care Homes System was launched in August 2017 to look at the events that led to Wettlaufer's offences and the contributing factors that allowed the crimes to happen, and to make recommendations to prevent similar crimes.

It was headed by Ontario Court of Appeal Justice Eileen Gillese.

Ontario Court of Appeal Justice Eileen Gillese presided over the two-year inquiry. (Wadham College/Twitter)

"This is about building confidence in the system again, and it's about recognizing that if there are deficiencies in how we provide health care to the elderly, we have to be honest about it and we have to address it," said Alex Van Kralingen, who represented several family members of Wettlaufer's victims at the inquiry.

"The impact of this inquiry's report is going to extend far beyond the people directly impacted by Ms. Wettlaufer's crimes."

The inquiry brought into focus the failures by the oversight bodies that should have caught Wettlaufer, if not for murder then for her negligent care of the elderly patients at the care homes at which she worked.

Wettlaufer worked for years without suspension, but her colleagues sounded the alarm on several occasions, beginning in 2012, the inquiry heard.

Near the end of her nursing career, Wettlaufer made regular medication errors that put residents at risk but was given a reference letter by her bosses at Caressant Care in Woodstock, in part because the home wanted to avoid a grievance from the Ontario Nurses Association.

Homes understaffed, nurses overworked

The inquiry also heard that many times, Wettlaufer was the only nurse overseeing the care of 99 patients, and that recruiting and retaining nurses at long-term care facilities was a constant battle.

After Wettlaufer confessed, the province's health ministry shut down Caressant Care to new patients while it investigated the home's shortcomings. Staff admitted it was the first time in years that they were able to give patients the care and attention they needed.

"The number of the residents got smaller but they didn't change the staffing, and they were finally able to provide the kind of care they wanted, to talk to people and not just from changing somebody to showering somebody to the next task," said Jane Meadus, a lawyer for the Advocacy Centre for the Elderly.

"People in long-term care homes need to be treated as people. We heard a lot about how most people think this is a place for people to go and die. And that attitude creates some of the problems, because people aren't being treated as human beings. Long-term care should be seen as a vibrant place where people can live and contribute."

The coroners who signed off on the deaths of Wettlaufer's patients didn't scrutinize the deaths because they happened in long-term care facilities, and nursing home staff didn't understand their obligations to report suspected neglect.

Meadus said she hopes the recommendations in the commission's report lead to a "culture change" where long-term care facilities are seen as valuable places to live and work.

"We want to see the recommendations respect the residents as people," she said.