Ontario must increase funding and staffing at the province's nursing homes to help prevent future serial killers from harming the most vulnerable, the final report into former nurse Elizabeth Wettlaufer's crimes recommends.

And nursing homes must limit their use of temp agency nurses and improve how medication is stored and tracked.

Those are just some of the 91 recommendations made by Justice Eileen Gillese in her four-volume report, stemming from the Public Inquiry into the Safety and Security of Residents in the Long-term Care Homes System.

"We cannot assume that because Wettlaufer is behind bars, the threat to the safety and security of those receiving care in the long-term care system has passed," Gillese said in her public remarks today in Woodstock, Ont., where Wettlaufer committed most of her crimes.

"People are now worried about whether the long-term care system can safely provide care for their loved ones and for themselves as they age."

Wettlaufer was a nurse in the province's nursing homes and, at the end of her career, a home-care nurse.

She committed her crimes from 2007 to 2016, mainly at Caressant Care nursing home in Woodstock, Ont. Her killings would not have come to light had she not confessed.

Elizabeth Wettlaufer is escorted from the courthouse in Woodstock, Ont., on Jan. 13, 2017. In January, 2018, she confessed to at least one more assault on a patient in her care. (Dave Chidley/Canadian Press)

"There is no simple 'fix' in terms of avoiding similar tragedies in the future," Gillese said.

"The offences were a result of systemic vulnerabilities in the long-term care system and not the failures of any individual or organization within it. Systemic issues demand systemic responses."

Gillese's recommendations focus on how to prevent, deter and detect health-care serial killers, as well as how to create enough awareness about the possibility that a health-care practitioner could be harming patients.

"While the long-term care system is strained, it is not broken," Gillese said, adding that the regulatory regime that governs the system and the people who work within it provide a "solid foundation" from which to address the systemic issues.

The recommendations

Gillese's recommendations will take political will and money. Among them:

The ministry of Long-Term Care should conduct a study to determine adequate staffing levels on day, evening and night shifts — and report on that study by July 31, 2020.

Increase funding for staffing as determined by that study. At times, Wettlaufer was the only nurse working on a night shift, overseeing 99 patients with no oversight.

Increase the number of registered nurses and registered practical nurses in long-term care homes.

Limit the use of temp-agency nurses, who go into long-term care homes with little knowledge of the residents and procedures, to fill staffing holes. Wettlaufer worked as an agency nurse when she tried to kill a patient in a Paris, Ont., nursing home in 2015.

Give grants ranging from $50,000 to $200,000 per long-term care home, depending on the size, to improve the infrastructure around medication, including how it is stored and tracked. That could include installing glass doors or windows onto medication rooms, installing security cameras in rooms where medication is stored or hiring a staff pharmacist. Wettlaufer herself told inquiry lawyers in an interview that glass doors on medication rooms would have made accessing insulin more difficult.

Give long-term care homes more flexibility to use funds to pay for a broad spectrum of staff, including porters or pharmacists.

Increase funding for training, education and professional development for everyone who provides care to residents in nursing homes.

Make free counselling services available for two years to Wettlaufer's lone surviving victim, the victims' families and their loved ones.

Ontario' Long-Term Care Minister Merrilee Fullerton said later Wednesday that the province will act on the first two recommendations of Justice Eileen Gillese's 91 recommendations to fix long-term care immediately.

Government responds

The government will review the long-term care system and will spend the next year acting on the recommendations contained in the report. It will deliver an update on its progress next year, as requested by Gillese.

That review will come with new funding for the province's long-term care facilities.

"This will be a government-wide approach. It will not be limited to one ministry," Fullerton said.

The province will also provide free counselling for the next two years for Wettlaufer's surviving victim and the family and loved ones of her victims, Fullerton said.

"Today is a solemn day, and I want to acknowledge the pain and the trauma and the impact this has had in the province," Fullerton said. "To the families, I want to say, your loved ones mattered, they had meaning, and they will make a difference."

More robust investigations

Gillese recommends the College of Nurses of Ontario, the profession's regulatory body, educate its members about the possibility of health care serial killers, and encourage nurses to work in long-term care homes.

The Office of the Chief Coroner is asked to redesign how it records patient deaths and to create a more robust investigation process for deaths, and to increase the number of death investigations it conducts in long-term care homes.

The coroner's office should also train staff within the homes on how to assess whether a resident's death is outside of the norm or "sudden and unexpected."

During the course of the inquiry, the commission heard that some coroners thought no death in a nursing home was "sudden and unexpected" because of the complex health needs of residents, and therefore didn't prompt any investigations.

Gillese didn't touch on the role the Ontario Nurses Association, the union that represents nurses, played in the system. During the inquiry, there was a lot of testimony about ONA's role in grieving Wettlaufer's suspensions and eventual firing. Gillese said the union's role was outside the scope of her report.

One nurse

Gillese dedicates her report to Wettlaufer's victims and their loved ones, saying "they serve as a catalyst for real and lasting improvements to the care and safety of all those in Ontario's long-term care system," she said. "Your pain, loss and grief are not in vain."

To the nurses who work in long-term care homes, Gillese says, "In opening our eyes to the one nurse who harmed, we must not forget the work of the many who are a credit to their profession."

The two-year inquiry 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.

The report examined 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.

She committed her crimes between 2007 and 2016, with most of the murders happening at Caressant Care nursing home in Woodstock, a city about 140 kilometres southwest of Toronto.

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

She pleaded guilty in 2017 to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault.

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

Caressant Care said Wednesday afternoon everyone in the long-term care system must work to restore public confidence.

"Caressant Care will carefully review these recommendations and may provide further comment as appropriate," the home said in a statement.

"However, due to the sensitivity of this issue and, out of respect for the families, residents and staff who have been deeply impacted by this tragedy, we ask for privacy."