WOODSTOCK, ONT.—For Jon Matheson, fully coming to terms with his mother’s murder remains somewhere in the distance, a place he’s not sure he’ll ever get to. But today, at least, he feels he got a little closer.

“I got some closure, I guess,” he said, after the release of a report on how to prevent a repeat of Elizabeth Wettlaufer’s nursing home murder spree, which included the killing of Matheson’s mother, Helen.

“You get more closure each time something good comes out of it, and if the good keeps happening, it gets easier to deal with,” he said.

The good Matheson felt Wednesday was the result of a four-volume report calling for sweeping changes to fix the “systemic vulnerabilities” that allowed Wettlaufer, a registered nurse, to kill nine people in two southwestern Ontario nursing homes between 2007 and 2016. Her crimes stopped only when she decided, unprompted, to turn herself in and confess.

The report’s release was followed by Ontario’s minister of long-term care, Merrilee Fullerton, promising “new funding to address the recommendations.”

“We are taking immediate action,” she told the families of victims gathered at a local hotel to read the report. “We will spend the next year acting on what we heard today.”

She didn’t reveal how much new funding would be provided, which recommendations the provincial government would adopt or when they would be implemented.

Her most concrete commitment was to table a study in the legislature by this time next year on the status of the government’s progress on implementing the recommendations. The law currently requires one registered nurse on site at all times, a number the Ontario Nurses’ Association has long described as grossly insufficient.

Matheson is willing to give the government some months to act, and will be keeping watch.

“The biggest thing is, what happens to the report after today?” he said in an interview. “Does the government take it and put it in a closet somewhere to collect dust, or will it act?”

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Matheson visited his 95-year-old mother every day during her two years at Woodstock’s Caressant Care, where Wettlaufer killed seven of her victims. Helen began her teaching career in a one-room schoolhouse near the town and was lucid until a couple of weeks before her death.

“Maybe I didn’t know what to look for,” said Matheson, 75, wondering if there was something in her care that he missed, something that would have alerted him to possible abuse. “You’re not there 24 hours a day so you don’t necessarily see what’s going on.”

The report was the result of a public inquiry headed by Justice Eileen Gillese. It describes Ontario’s long-term-care system as “strained but not broken” and says “there is no need to jettison the existing regulatory system and start over.”

Its 91 recommendations include more intensive ministry oversight of nursing homes; more ministry funding for training and education of nursing home staff; increasing the number of registered nurses and staff in the homes; and urging nursing homes to build a more stable supply of staff while limiting the use of agency nurses who roam from one workplace to another.

It also called for government grants of up to $200,000 per home to make infrastructure and other changes to better secure medication. Wettlaufer murdered her victims with overdoses of insulin.

The report does not say how much extra ministry funding all the recommendations would require. But with 626 nursing homes in Ontario, the price tag is significant.

“The best way to prevent similar tragedies is to strengthen the long-term-care system,” said Gillese, a judge on Ontario’s Court of Appeal.

The report urges the ministry to “play an expanded leadership role in the long-term-care system.” The ministry should ensure that a “strategic plan is in place to build awareness of the health-care serial killer phenomenon” and instruct the Office of the Chief Coroner to develop and implement it.

The ministry should also set up an internal unit dedicated to helping nursing homes comply with regulations and use best practices, it says.

At Queen’s Park, the Opposition NDP called on the Ford government to immediately lay out a plan to implement the recommendations, with timelines. It also called for the inquiry to be extended to examine conditions in seniors’ care, including nutrition and staffing, and how they affect residents every day.

Families of Wettlaufer’s victims generally welcomed the report.

“It makes me feel a little better about what happened,” said Joanne Birtch, daughter of James Silcox, Wettlaufer’s first murder victim.

When Birtch’s father died, Wettlaufer told Birtch’s sister an autopsy wasn’t needed. Birtch’s sister then asked the local coroner directly for an autopsy, “and he was quite short with her and said your father died in long-term care so there’s no need,” Birtch said.

“Does that mean he wasn’t important anymore?” she added in an interview. “My dad was a contributing member of this community and a war veteran and he deserved better.”

The report calls on coroners to increase the number of death investigations in nursing homes. The coroner’s office should also use data models to identify homes with a higher than expected number of deaths, it says.

During its almost 40 days of public hearings, the inquiry heard that an emergency room doctor and nurse at Caressant Care considered the death of a Wettlaufer victim suspicious and asked that the local coroner investigate. The coroner refused.

Alex Van Kralingen, a lawyer representing the families of four murder victims, said he was encouraged by the report and the government’s response. The government is signalling it wants to move relatively quickly with changes, “and I can tell you that my clients are going to hold them to that promise,” he added.

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But Jane Meadus, a lawyer representing the Ontario Association of Residents’ Councils, said she was “disappointed” the report didn’t focus more extensively on funding gaps and failed to recommend that all nursing homes get full inspections annually, which isn’t happening now.

“Yes, we need to know about health-care serial killers, but we also need to know about good care,” Meadus said in an interview. “And if the ministry is not looking to see if good-quality care is happening, we don’t know that it will.”

Fullerton was accompanied by Ontario Health Minister Christine Elliott, Solicitor General Sylvia Jones and Ernie Hardeman, the agricultural and rural affairs minister. They all met privately with family members of the victims and promised to update them on reforms.

In her speech to family members, Gillese stressed that a serial killer can strike again.

“To avoid similar tragedies in the future, it is critical that awareness is developed throughout the health-care system of the possibility that a health-care provider could intentionally harm those in their care,” she added.

The report is dedicated to the victims and their loved ones. “Your pain, loss and grief are not in vain,” it says.

“The victims’ family members and loved ones continue to struggle with feelings of sadness, anger, guilt, grief, anxiety, fear, depression and betrayal,” it adds. “Some have lost trust in health-care professionals, people in positions of authority and the government. Others have withdrawn from family and friends, and most have difficulty eating, sleeping and focusing.”

The litany of errors and oversights that allowed Wettlaufer to continue killing undetected are summarized in the report. But it makes no findings of misconduct because the offences “were the result of systemic vulnerabilities in the long-term-care system.”

“What this finding highlights is that there is no simple ‘fix.’ We cannot point our fingers at any given individual or organization, identify the shortcomings we find there, and end the threat posed by wrongdoers such as Wettlaufer by remedying those shortcomings.

“Systemic issues require a systemic response,” the report says.

Gillese made a point of “debunking” the myth that Wettlaufer performed “mercy killings.”

“When Wettlaufer committed the offences, the victims were still enjoying their lives and their loved ones were still enjoying time with them. It was not mercy to harm or kill them,” Gillese said, noting Wettlaufer confessed she murdered out of anger about her career and the sense of “euphoria” she felt when killing.

“Like other serial killers, she committed the offences for her own gratification and for no other reason.”

Ninety health-care serial killers have been convicted since 1970 in the U.S., Britain and Western European countries.

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.

The next two decades saw Wettlaufer disciplined dozens of times for medication errors, poor treatment of residents, 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 in her employment file, from residents and co-workers.

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.

Wettlaufer pleaded guilty to killing eight patients under her care at Caressant Care and Meadow Park nursing home in London. While serving a life sentence she confessed to killing a ninth person, a resident at Meadow Park. The ninth death linked to Wettlaufer, in August 2014, wasn’t dealt with by the inquiry.

Caressant Care’s owner and president, Jim Lavelle, thanked the inquiry for “thoughtful, practical recommendations that can improve the long-term-care system and enhance the safety, security and quality of life for residents.”

The report calls on the college to educate its staff on the possibility that health-care providers might intentionally harm patients, and revise its procedures with that in mind.

The college must also strengthen its investigation process by better training its staff.

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.

Correction - August 1, 2019: This article was edited from a previous version that mistakenly said Minister Merrilee Fullerton would table a study in the legislature this time next year on the number of extra staff needed to keep nursing homes residents safe. In fact, the study to be tabled will be on the progress made in implementing the recommendations.

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