ST. THOMAS, ONT.—Employers began raising red flags about “rogue nurse” Elizabeth Wettlaufer as early as in her first job out of nursing school, a public inquiry into the deaths of eight elderly patients heard on opening day.

Wettlaufer got fired from the Geraldton District Hospital in 1995 after she was caught high on drugs that she admitted stealing on the overnight shift, a packed courtroom was told. The next two decades saw Wettlaufer disciplined multiple times for a litany of medication errors, conflicts with co-workers, poor treatment of nursing home residents and generally shoddy work.

The public inquiry, which began Tuesday, documented the shocking systemic failings that allowed Wettlaufer to rampage through Ontario’s long-term care system, ending only when, unprompted, she confessed in September 2016 to killing eight people in her care by injecting them with overdoses of insulin.

The son of the eighth person murdered by Wettlaufer said he wanted those who failed to prevent his father’s death held to account.

Read more:

Coroner rejected autopsy in home where Elizabeth Wettlaufer killed seven people, documents suggest

‘That evening, I got the urge to overdose James’: Read serial killer Elizabeth Wettlaufer’s handwritten confession

Inside the troubled life of Elizabeth Wettlaufer, the nurse on the night shift

“I want to see the health system revamped — nursing care, senior care,” Arpad Horvath Jr. told reporters outside the inquiry. “But mostly I want to see the people who are accountable be crucified in the public eye, online and everywhere.”

Wettlaufer, 50, was fired in March 2014 from the Caressant Care nursing home in Woodstock, Ont., where she killed seven of her eight victims. The home notified the College of Nurses of the firing. But the college, responsible for keeping the public safe from bad nurses, didn’t investigate Wettlaufer, leaving her with a spotless public record.

The firing came after Caressant managers noted more than 130 incidents of complaints from residents and workers in Wettlaufer’s employment file during her seven years at the nursing home, according to a chronology put together by the inquiry’s legal team. But when Wettlaufer grieved her firing, Caressant managers agreed to a demand from Wettlaufer’s union, the Ontario Nurses’ Association, to pay her $2,000 in damages.

Caressant also agreed to a union demand that provided Wettlaufer with a “reference letter,” which she could use to get another job. The letter said Wettlaufer left Caressant “to pursue other opportunities,” according to the chronology. The letter, the inquiry officials noted, also described Wettlaufer as a “good problem solver,” who is punctual and has good communication skills.

Wettlaufer was then hired by the Meadow Park nursing home in London, Ont., where she killed again. Before hiring her, officials at Meadow Park called two registered nurses who worked with Wettlaufer at Caressant Care and both gave her positive reviews, one describing her as a ‘good worker, very good with residents.”

Tom Friedland, legal counsel for the Ontario Long Term Care Association, said he wants the inquiry to address systemic failings, including “the need to review the grievance process so that rogue employees such as Elizabeth Wettlaufer do not receive favourable letters of recommendation.”

The inquiry also revealed that three of Wettlaufer’s victims were reported to local coroners, raising further questions about whether a chance to catch Wettlaufer before she continued killing was missed. One of the deaths was considered “suspicious,” but a local coroner refused to investigate, according to Ministry of Health and Long-Term Care documents obtained by the Star through a freedom of information request.

The documents from ministry inspectors list several patients who died at the home, their names redacted in the notes. At the end of the redacted names is a comment suggesting that both an emergency room doctor and a Caressant registered nurse believed the coroner should investigate a death.

“Identified by ER physician as should be a coroner’s case, identified by (RN) Karen Routledge as suspicious, asked for an autopsy, coroner did not feel this was appropriate,” says the inspection note, emailed by inspector Rhonda Kukoly to her colleagues on Nov. 18, 2016.

A report released by the public inquiry Tuesday does not describe the death referred to in the inspection notes as suspicious. But it makes clear the incident occurred March 28, 2014, and names the victim as Maureen Pickering, killed when Wettlaufer gave her a lethal injection of insulin.

“It appears that a local coroner was also contacted in relation to Maureen Pickering’s death ... because of a recommendation made by the Woodstock hospital emergency physician who had treated Ms Pickering five days earlier, but the local coroner declined to investigate the death,” says the overview report, compiled by officials with the inquiry.

The report says Routledge, the registered nurse, also called local coroner Dr. William George, who said he “did not feel this was a coroner’s case.”

Cheryl Mahyr, issues manager at the Office of the Chief Coroner, said privacy laws prevent her office from commenting on any investigation that might be conducted. She noted that deaths at long-term care facilities get reported to the coroner’s office, but not all get investigated.

Loading... Loading... Loading... Loading... Loading... Loading...

The coroner’s office conducts 16,000 investigations a year in Ontario, which result in about 7,000 autopsies being performed, she added.

“Because of their training and their knowledge, they don’t necessarily require an autopsy to determine cause and manner of death,” Mahyr said, noting that Ontario coroners are licensed medical doctors. “They can make those determinations, more often than not, based on medical history and circumstances of the death.”

Commissioner Eileen Gillese presided during the inquiry’s opening day at the Elgin County courthouse. The commission’s legal team reviewed more than 41,000 documents as it investigated four separate areas: the long-term care homes and home-care agencies that employed Wettlaufer; the Office of the Chief Coroner and Ontario Forensic Pathology Service; the College of Nurses of Ontario; and the province’s health ministry.

There are 627 long-term care homes in Ontario, and nearly 79,000 beds.

The inquiry’s co-lead counsel Mark Zigler said the ultimate aim of the probe is to identify systemic failures and restore public confidence in Ontario’s long-term care and homecare systems.

“We recognize that resident safety is paramount and believe the possibility that another Wettlaufer may be out there is a matter of concern,” Zigler said, adding the overwhelming majority of health-care workers are trustworthy.

“There is no suggestion that these events will be repeated in Ontario, but there is also no guarantee that they will not,” he continued.

Wettlaufer pleaded guilty a year ago to killing eight residents under her care in two nursing homes, and seriously harming six others. She was sentenced to life in prison, with no chance of parole for 25 years.

Back in 1995, nurses coming to work on the morning shift at Geraldton District Hospital found Wettlaufer stumbling, slurring her speech and vomiting, the inquiry’s senior counsel Liz Hewitt said, running through the convicted serial killer’s spotty track record.

Wettlaufer, then a newly graduated registered nurse, kept changing the story of why she had taken the anti-anxiety drug Ativan from the hospital’s locked medicine cabinet and how much of it she had consumed.

She told some colleagues she had taken two pills to “take the edge off and get through the night shift.” To others, she said she had taken four pills. And to others, she said she took 25 pills in an attempt to kill herself.

Wettlaufer successfully grieved the termination to her union, the Ontario Nurses’ Association. As part of a settlement between the union and hospital, her employment record was amended to state that she had resigned on her own accord for health reasons.

The incident also landed her on the radar of the College of Nurses of Ontario, the regulator for the profession. Addressing the incident as a substance abuse problem, the college’s Fitness to Practice Committee placed restrictions on her licence for a year. She agreed not to abuse any substances and to get help.

Both the union and the college have standing at the inquiry, which is exploring how shortcomings across the health-care system enabled Wettlaufer for nine years to go undetected as patients died.

Wettlaufer’s next job was as a personal support worker at a facility for individuals with developmental disabilities. She ran into trouble there too. Within the span of a single month, she was cited three time for failing to account for patient medication. The facility was made aware of the restrictions on her nursing licence.

Nevertheless, it gave her a glowing reference letter when she moved on to her next job.

Final recommendations from the inquiry are expected by July 31, 2019.

Read more about: