A coroner refused to conduct an autopsy on a “suspicious” death in the nursing home where registered nurse Elizabeth Wettlaufer murdered seven of her eight victims, according to Ministry of Health and Long-Term Care documents obtained by the Star.

The allegation is contained in notes made by ministry inspectors while preparing to investigate the Caressant Care nursing home in Woodstock, Ont., a month after Wettlaufer was charged with the multiple murders in October 2016.

The notes, obtained through a freedom-of-information request, list several patients who have died at the home, their names redacted in the documents. 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.

The incident was confirmed in an overview report released Tuesday by the public inquiry into how Wettlaufer was able to kill and harm nursing home residents undetected for years until she confessed to her crimes, without prompting, in September 2016.

The overview report outlines the involvement of the Office of the Chief Coroner and local coroners with Wettlaufer’s victims. It does not describe the death referred to in the document as suspicious. But it notes that it 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 in Hospital, but the local coroner declined to investigate the death,” says the overview report, compiled by officials with the public inquiry.

The report says Routledge, the registered nurse, also called local coroner Dr. William George.

“Dr. George called back and did not feel this was a coroner’s case,” the report says.

The report also notes that local coroners were contacted about two earlier victims of Wettlaufer’s at Caressant Care. One was James Silcox, who was Wettlaufer’s first murder victim in August 2007. The other was Wayne Hedges, who Wettlaufer attempted to kill with insulin between September and December 2008. He died Jan. 24, 2009. The local coroner was called because Hedges was the 10th person to die in the home, and the third in 24 hours.

In the Silcox case, Wettlaufer herself completed the form about his death sent to the coroner’s office. Dr. George, the local coroner, investigated Silcox’s death in September 2007. He ruled that he died as “a result of complication following a fall in which he sustained a right hip fracture,” the overview report states.

Former Ontario nurse Elizabeth Wettlaufer has been sentenced to life in prison with no parole for 25 years for murdering eight seniors in her care. The granddaughter of one victim says Wettlaufer is “getting what she deserves.” (The Canadian Press)

After Pickering’s murder, Wettlaufer killed another resident in a nursing home in London, and attempted to kill two other people in her care.

The three cases reported to local coroners raise questions about whether a chance to catch Wettlaufer before she continued killing was missed.

The deaths of Wettlaufer’s six other victims at Caressant Care were reported to the coroner’s office, but Caressant staff did not contact a coroner directly because circumstances were deemed to not meet the criteria for doing so.

Dr. Rich Mann, regional supervising coroner for western Ontario, refused to comment when contacted by phone by the Star. 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.

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

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

“Because of their training and their knowledge, they don’t necessarily require an autopsy to determine cause and manner of death,” Mahyr said, noted 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.”

Ontario’s chief coroner, Dr. Dirk Huyer, will be testifying at the public inquiry, which began Tuesday, into how Wettlaufer was able to kill and harm nursing home residents undetected for years until she confessed in September 2016.

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.

The public inquiry will also place the spotlight on the College of Nurses of Ontario, responsible for protecting the public from bad nurses. It failed to investigate Wettlaufer when Caressant Care informed the college the nurse was fired in March 2014 because of medication errors that put the life of a resident at risk.

Read more about: