Elizabeth Wettlaufer came home from rehab the day after police in white forensic suits combed through her Woodstock apartment and hauled out evidence. She had yet to be charged for the murder of eight nursing home residents under her care, but her world was collapsing around her.

It was shortly after Wettlaufer, a 49-year-old registered nurse, had signed an Oct. 6 peace bond banning her from providing health care and placing her under a 7 p.m. curfew, except for AA meetings.

She started packing to go live with her parents nearby, and served notice she would be vacating the fifth-floor, two-bedroom unit she had called home for at least nine years.

Neighbours didn’t know about the bond, but Wettlaufer made no secret about the instability in her life. They knew her as the friend who one day announced she had “found God and wasn’t a lesbian anymore,” as the recovering drug addict who twice spent time in rehab, as the tenant behind in her rent.

When her bags were done, Wettlaufer asked a neighbour what kind of gossip the police search had sparked.

“I said to her, ‘People are saying you killed someone,” said the neighbour, who spoke on the condition she not be identified. “And she starts laughing her head off. She was hysterical. She thought the whole thing was funny.”

Police have not named the deadly drug they allege Wettlaufer “administered.” But the peace bond banned her from specifically possessing insulin, and any controlled drug that wasn’t prescribed.

A source familiar with aspects of the investigation said Wettlaufer once offered to put down a neighbour’s sick cat with insulin she had in her apartment. Contacted by the Star, the neighbour denied having told the story to police and insisted the offer never happened.

There’s more agreement about Wettlaufer saying she got hooked on drugs while on the job at Woodstock’s Caressant Care nursing home, where seven of the eight people were allegedly killed.

She told her neighbour Nancy Gilbert she got the drugs from the medication cart she controlled as a registered nurse. “She said she got to the point where she didn’t want it to control her life or her job,” said Gilbert, 56, explaining Wettlaufer’s first tour in rehab, which occurred before she met the nurse two years ago.

Wettlaufer’s LinkedIn profile said she worked at Caressant from June 2007 to March 2014. Judging from a dramatic Facebook post, her first day off drugs was in late September 2014. (On Sept. 28, 2015, she wrote on Facebook: “My own voice called me in the darkness. Other hands lifted me when I chose the light. One year ago today I woke up not dead. 365 days clean and sober.”)

Gilbert doesn’t know under what circumstances Wettlaufer left Caressant Care. But the neighbour who saw her laughing the day of her return from rehab claimed it involved an incident when she was high on drugs.

“She said she lost her job because she accidentally gave someone the wrong medication because she was fried,” the neighbour said. “She wasn’t fired. They said if she left quietly they would just let it go.”

Wettlaufer’s next job was at the Meadow Park nursing home in London, where she is accused of killing the last victim, 75-year-old Arpad Horvath, sometime during a week-long period in August 2014. The neighbour’s claims raise questions of whether at least one life could have been saved.

Officials at both Caressant Care and Meadow Park declined to answer emailed questions asking if they knew Wettlaufer was a drug addict, whether she was fired or asked to resign, or whether her conduct was reported to the College of Nurses of Ontario, which regulates the profession.

Representatives of both homes referred the Star to their statements in late October, which said they were co-operating fully with the police investigation and did not want to compromise it with further comment.

What’s known is that Wettlaufer remained a registered nurse until she “resigned” on Sept. 30, 2016, according to the college’s website. That likely occurred while Wettlaufer was under the care of the Centre for Addiction and Mental Health in Toronto, where she gave staff information that caused them to alert police about the deaths, according to a source with knowledge of the investigation.

Employers must alert the college “if there is a concern that a nurse is not practicing safely,” says a college document on mandatory reporting. The college must also be informed if a nurse is fired, or if a nurse is “incapacitated” by a health condition, including addiction.

“A nurse who is found to be incapacitated may be required to comply with appropriate medical treatment before returning to practice,” the college says.

A college spokesperson, Denise Riposati, would not say if the college ever received a complaint about Wettlaufer, or investigated her.

Nursing homes don’t need to notify the college if nurses resign, unless managers had planned to fire them, the college document says. A quiet resignation avoids a potential costly union grievance, or a complaint to the Ontario Human Rights Tribunal, which considers addiction a disability and recently ruled a nurse could not be fired because of it.

“When a nurse is suspected of substance abuse or stealing meds an investigation is initiated,” a senior long-term-care official said in an email to the Star’s Theresa Boyle. “It is very hard to prove it and it takes quite a bit of time.”

Linda Haslam-Stroud, president of the Ontario Nurses Association, the union that represents registered nurses at Caressant Care, declined an interview request on whether Wettlaufer had ever been the subject of complaints, and on the reporting of performance concerns to the college.

Laura Jackson and Don Martin were good friends with Maurice Granat, 84, Wettlaufer’s second alleged victim. They visited the long-time auto body shop worker at Caressant Care at least once a week.

On Dec. 23, 2007, they received a call at about 4 a.m. from someone at the Woodstock facility saying Granat — known to them as “Moe” — was not well. They rushed to the nursing home.

Martin entered the room and saw Granat struggling with a nurse he says he recognized as Wettlaufer after seeing photos of her arrest. Granat’s arms were flailing and he was making strange noises. Martin held his hand and Granat calmed down.

To Granat’s friends, the nurse appeared gruff. “She just said, ‘Get out of my way. Get out of my way,’” Jackson said.

She left the room and returned moments later with a needle. She shoved Jackson aside and said, “This will soothe him now.”

About 20 minutes later, Granat gasped his final breath. Jackson and Martin have no idea what medication was administered and there is no evidence it led to the death.

Neither Jackson nor Martin thought often about that day, until they saw Granat’s name on the front page of the Star. They were “gobsmacked” and “floored.” And they can’t stop thinking about it.

“It’s spinning in my mind,” Martin said. “I never heard (before) what he sounded like that day. He was struggling with her. Was he fighting her? What was going on before we’d been there?”

Caressant Care is a sprawling, for-profit nursing home with 193 beds on a quiet street in Woodstock. In the busy front foyer, a television wishes patients happy birthday through a slide show of smiling nurses with happy residents. Taped to the wall are “certificates” trumpeting government inspections that gave clean bills of health.

Wettlaufer usually worked the night shift, 11 p.m. to 7 a.m. There are no managers or supervisors at that time, and as the only RN on site, Wettlaufer was the boss, says Ross Gerrie, president of the Unifor local that represents 135 workers at Woodstock’s Caressant Care, including registered practical nurses and personal support workers.

Ontario law requires no more than one RN on site at all times, a number so inadequate “it’s a disgrace,” said Doris Grinspun, CEO of the Registered Nurses Association of Ontario.

Wettlaufer’s main responsibility was the administration of drugs. At the start of her shift, she would count and note the number in the medication cart with the nurse ending the previous shift. The exercise would be repeated when Wettlaufer passed the cart to the morning nurse.

She supervised a night staff of one registered practical nurse and eight personal support workers, according to a knowledgeable worker at the home. These 10 people, including Wettlaufer, were responsible for 163 nursing home residents, who sleep four to a room.

Most workers are part-time, juggling jobs. If one calls in sick, the workload for everyone else tends to increase because replacements are difficult to find and management won’t call one in if overtime needs to be paid, Gerrie said. “This problem is industry-wide,” he added.

“There is no legislation that requires a certain number of minimum hours of care per patient, so the home piles the work on to the next person,” he said. That could result in only one PSW lifting a resident to go to the washroom instead of two, as required by regulations, he added.

“So the workers are in jeopardy because they’re more susceptible to injury and the patients are in jeopardy, too, because there’s not enough people to care for them,” he said. “This is everyday stuff.”

Wettlaufer was always ready to help whenever she could, says one worker who watched her perform for years at Caressant Care.

“She was a good nurse and great to work with,” said the worker, who didn’t want to be named for fear of being fired. “I never heard anyone complain about her performance.”

Caregivers are under instructions to limit diapers to three per resident per day. But Wettlaufer, who controlled a master key, was always ready to provide more when asked.

“She was great with the residents,” the worker said. “I’ve never seen her not be nice to anybody.”

In an online poem she wrote six years ago, titled “Working Happy,” Wettlaufer described her love of old people, “their wrinkles, their frailties, their refusing to eat anything but icecream, even their smell. I love the finality, the resignation, the knowing this is their last home.”

One day in 2014 Wettlaufer was suddenly gone from Caressant. Gerrie said members he spoke with have no idea why she left.

Since the charges against Wettlaufer were announced in late October, three managers at the nursing home have resigned, for reasons unclear, Gerrie said.He added that an inspector with the Ministry of Health and Long-Term Care is on site each day, questioning residents and staff about conditions.

On the ministry’s website, it is common to find inspections about specific complaints where Caressant’s Woodstock home is given a clean bill of health. But the two general inspections posted — in 2014 and 2015 — found numerous deficiencies.

“In resident bathrooms noted a wall visibly stained with urine, brown/yellow substance around the base of toilets,” says the 2015 general inspection, “bathroom floor tiles had a build-up of black debris/dirt, toilet rims with mounted Versa frames visibly soiled with green/black/white substances behind the toilet seat, rust stains in toilet bowls … and dried food on the walls of a dining room.”

In 11 of 27 complaints by residents, the 2015 inspection could not find documents stating the case had been resolved. The inspector also cited safety concerns about an unlocked stairwell door.

A December 2014 inspection said the home “failed to ensure that drugs are stored in a medication cart that is secured and locked.” It spotted a nurse leaving the cart unattended “for several minutes” near the dining hall, “with drugs available on top of the medication cart.”

Another inspection that year noted a resident was injured while being lifted by personal support workers who had not received training, and eight residents didn’t receive baths due to staffing shortages.

Wettlaufer’s alleged victims ranged in age from 75 to 96. Their friends and relatives say they never suspected a thing.

In a 24-day period beginning Oct. 14, 2011, she is accused of killing three people, including 95-year-old Helen Matheson, a former teacher who began her career in a one-room schoolhouse in Innerkip, near Woodstock.

Helen lived two years in Caressant and her son, Jon Matheson, visited her every day. She was lucid and mobile until a couple of weeks before her death, when Matheson noticed her “going downhill quickly.” She suddenly refused to eat.

“I’m thinking it’s old age,” said Matheson, 72.

On Oct. 13, Matheson got a call from someone at the home saying his mother was living her last moments. He arrived at about 7 p.m. and sat at her bedside. He dozed off several times. He opened his eyes at one point past midnight and his mother was dead.

“She never complained of being mistreated at the home,” said Matheson, who can’t recall ever seeing Wettlaufer there. “And I always thought people were looked after fairly well.”

This year, on Oct. 7, an OPP officer visited Matheson’s home and identified himself as “the lead investigator” in the alleged murders. “He said they had no idea about a motive,” Matheson said. When Matheson asked if his mother’s body would need to be exhumed, the officer said, “We don’t know yet.” Three weeks later police told reporters bodies would not be exhumed.

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“How could this have happened?” said Matheson, a logger in B.C. for almost four decades before he returned to look after his mother. “There’s supposed to be all kinds of checks and balances.

“I try to think back, was there something I missed? I can’t come up with anything, really. And that’s the frustrating part.”

Victims of health-providers-turned-serial-killers are often the most defenseless, including infants, people with developmental delays and adults with dementia, said Beatrice Crofts Yorker, co-author of a 2006 study on doctors, nurses and nurses’ aides who kill. And once these caregivers realize how easy it is, “They sort of get emboldened.”

The study, published in the Journal of Forensic Sciences, found 90 worldwide prosecutions of health providers for serial murders since 1970. Fully 86 per cent of them were nurses. Of the 54 convicted at the time the study was published, all but three were charged for killings in Europe and the U.S. The convicted were found guilty of killing 317 patients and suspected in the deaths of 2,113 others.

Most killings occurred in hospitals; 13 of the convicted murdered in nursing homes. Injections of non-narcotic medications, including insulin, were the preferred method.

“The attractive thing about insulin is that it can take a long time to kill someone,” Yorker said in an interview. “Insulin has a lot of variability. You can be completely done with your shift, gone home, not even on the unit when a patient dies.”

Mistaken doses of insulin rarely kill. The amount needed to take a life requires premeditation, said Yorker, a professor of nursing and criminal justice at California State University, Los Angeles.

The murdering caregivers showed evidence of personality disorders. Motivations included “sadistic satisfaction,” the killing of “demanding” patients, and “the pressures of a heavy workload and needing to free up beds,” the study found.

A lack of oversight during evening and night shifts was noted as a factor. The study also noted the pressures on health care facilities to let nurses they have suspicions about quietly leave.

“At present, risk management approaches seem to favor policies geared toward preventing lawsuits for wrongful termination, denial of employment or defamation,” the study says.

“A better balance is needed between the employment rights of caregivers and the ability of healthcare facilities to know about the backgrounds of employees. We encourage healthcare employers to be forthcoming with references that include information that a healthcare worker was fired, or to provide information regarding adverse patient outcomes associated with the presence of a particular caregiver.”

If convicted, Wettlaufer will be Canada’s first confirmed health-care serial killer. She has yet to enter a plea, and will next appear in court via video link Jan. 6.

Jim Van Allen, a former OPP criminal profiler who was part of the team that nabbed serial killer Russell Williams in 2010, noted her alleged murders are scattered between August 2007 and August 2014, with only one cluster of three in 2011.

“If I was on the investigation I’d be inclined to look back at what’s going on in that person’s life at the time of the murders,” he said in an interview. “It might be explained by their relationship with the patient or some other stress that’s going on in their life.

“You can bet police are plotting this out on a timeline,” he added.

Wettlaufer was born Elizabeth Parker and grew up with a brother in a religious household in the Woodstock area. She was a member of her high school’s band and choir, and received a bachelor’s degree in religious education counselling from the London Baptist Bible College, now called the Heritage Baptist College.

She became a registered nurse in June 1995. She met the man she would marry, a truck driver who works nights, at a Baptist church. They tied the knot in October 1997 and lived in a modest white bungalow on Woodstock’s Winniett St.

They had no children, and began living apart in January 2007, seven months before the first alleged murder. In May 2008, her husband, Daniel, applied for a divorce, noting in a document “there is no chance of reconciliation.” The uncontested divorce was finalized six months later.

The ex-husband, who did not respond to requests for an interview, told a neighbour he wished she had reverted to her maiden name after the divorce.

Early in 2008, through a chat room on the website Gay Canada, Wettlaufer connected with Sheila Andrews. That summer she flew to Prince Albert, Sask., to spend a week with Andrews at her home.

“When she got off the plane she almost body-slammed me,” said Andrews, 49. “She’s like, “I’ve been telling everybody how much in love I am with you and we were going to get together and everything.’ And I’m just, like, ‘Whoa, slow down, sweetheart. We’re just meeting.’ That’s what kind of scared me off.”

Wettlaufer struck Andrews as “a very nice person.” But Andrews avoided physical intimacy because “the chemistry wasn’t there.” It left Wettlaufer bitter and disappointed, she said.

Wettlaufer told Andrews her marriage didn’t work out because “she was interested in women.” Andrews “got a sense” that Wettlaufer was “in the closet because of her religious upbringing.”

In one online poem, “I Never,” Wettlaufer laments yearning for someone but being too “terrified to even steal a kiss. And now I wonder why. Why did I keep myself apart, why did I give in to so called morality, why did I let rules rule me?”

The only serious relationship, since her divorce, that neighbours know of was in 2011, the year Wettlaufer is accused of killing three people. A woman moved in with her for four months. The woman told Oshawa resident Patricia Crosbie, who was living with the woman’s son at the time, that the reason Wettlaufer gave her for breaking up was that she was no longer a lesbian.

The ex-girlfriend refused to comment when contacted by the Star. She insisted, however, that Wettlaufer “was not violent, I’ll say that much.”

Neighbours then started hearing gospel music in Wettlaufer’s apartment. One day, while sitting outside the building on a hot night with friends, the conversation turned to relationships and one recalls Wettlaufer saying, “Oh, I found God and I wasn’t a lesbian anymore.”

She lived with two cats and a dog she rescued, a Jack Russell terrier named Nashville. “She said that she enjoyed being on her own, because she had her animals, and she spent a lot of time with her mom and dad,” said her neighbour and friend, Nancy Gilbert.

Wettlaufer also has a brother in Halifax. In 2011, she posted on a poetry website that she had spoken with him for the first time in two years. He declined an interview request, as did Wettlaufer’s mother.

Also in 2011, under the pseudonym Betty Weston, Wettlaufer published an online poem about a woman trying to “quench her craze” by stabbing someone to death. In the comments section below the poem she wrote that making the killer a woman “made me feel powerful.”

Wettlaufer changed jobs frequently after Caressant Care. She spent a few months at the Meadow Park home in London, and then worked temporary nursing contracts, between February 2015 and August 2016, at three long-term-care homes in Paris, Brantford and Port Dover, all owned by Revera Homes. This summer, she worked part time as an in-home care provider for Saint Elizabeth Home Health Care.

Gilbert describes her as “very easygoing, very friendly.” But Wettlaufer’s next-door neighbour suspects her of taking part in a three-year campaign of vandalism and harassment against him. What’s certain is that Wettlaufer called the children’s aid society when the neighbour’s 3-year-old boy was found wandering the hallway in 2015. The neighbour was convicted of abandonment, but soon regained guardianship.

He says he was on his balcony this summer when Wettlaufer leaned around the balcony partition and “apologized for the harassment over the years.”

“Then all of a sudden she starts to confide in me,” says the 54-year-old neighbour, who used to run a roofing company. “I couldn’t believe what I’m hearing because we’ve basically been enemies for the last three years.”

He claims Wettlaufer told him she “got fired from one job for stealing medication,” and got fired from a second job because — in words the neighbour said she used — “I was high when I gave the patient the wrong medication and he almost died.”

In early September, Wettlaufer found her dog a new home, a move that struck her friends and neighbours as strange considering how much she loved the terrier. Then she told them she was off to rehab.

She returned in early October, after police had searched her apartment, and spent her curfew hours at her parents’ home. The peace bond she signed ordered her to “continue any treatment for mental health” with doctors.

Four days before her arrest she had supper with Gilbert and another neighbour.

“She was in a great mood,” Gilbert says. “We joked around and had a really nice meal. I knew she had a curfew, but it just didn’t kick in why.

“When this came to light I just couldn’t believe that they were talking about the same Beth, because I had no idea, none whatsoever — if this is true — that she could ever do something like that.”

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