A system set up to protect patients instead allowed a nurse to go on killing the frail and elderly in her care for almost a decade, a public inquiry into the province's long-term care system has heard.

It was clear from the moment she began her career in 1995 that there were issues with nurse Elizabeth Wettlaufer, documents released as part of the inquiry reveal.

In 1995, Wettlaufer was fired from the Geraldton, Ont., District Hospital, where she was a student nurse, after overdosing on narcotics she stole from the hospital during a shift.

The nurse who pleaded guilty to killing eight seniors with fatal doses of insulin is shown here in a taped confession in October 2016. 'I had a feeling inside of me,' she told police. 0:44 But Wettlaufer continued working at half a dozen other facilities in the next two decades, killing eight patients in her care by injecting them with insulin, and trying to kill or harm six others.

Eventually, Wettlaufer confessed her killing spree to a social worker and psychiatrist, when she herself realized she shouldn't be trusted to administer insulin to children. She pleaded guilty in court to the murders and attempted murders and was sentenced June 26, 2017 to life in prison with no chance of parole for 25 years.

"Why was she able to get away with this undetected?" asked Mark Zigler, the co-lead counsel for the public inquiry.

Although the inquiry won't be able to answer why Wettlaufer killed, it hopes to spell out to the public why she was able to keep killing, and how the system can change to prevent future killings, Zigler told Commissioner Eileen Gillese.

"It is a total betrayal of trust when a caregiver does not prolong life, but instead terminates it," Zigler said.

Tuesday was the first day of the public inquiry.

Zigler detailed the ways in which Wettlaufer harmed or killed the elderly patients in her care, with family members of the victims once again having to hear how their loved ones died.

"I want everyone accountable to be crucified," Arpad Horvath Jr. told reporters outside the inquiry on Tuesday. His father was killed by Wettlaufer in August 2014.

Documents posted online reveal just how much, and how often, the system designed to protect patients failed those people. Those failures include:

After she was fired for stealing medication and overdosing in 1995, the Ontario Nurses Association intervened, and her firing was noted as a voluntary resignation.

From 2007 to 2014, Wettlaufer worked at Caressant Care in Woodstock, Ont., where she killed seven people. During that time, she was reprimanded nine times for numerous medical errors and incompetence until she was fired in 2014.

Her firing from Caressant Care was noted as a voluntary resignation after the Ontario Nurses Association again intervened. Wettlaufer got $2,000 as part of her union settlement and a letter of recommendation.

Wettlaufer began working at Meadow Park Long Term Care in London. Meadow Park administrators called police, because they suspected the nurse had stolen narcotics. No one called the College of Nurses of Ontario, the regulatory body that oversees the province's nurses. It's not clear what happened to the police investigation.

The Ontario Coroner's office was tipped off twice about problems with deaths at long-term care facilities where Wettlaufer worked. However, autopsies were not performed in those unexpected and suspicious deaths to determine their cause.

In her opening remarks, Commissioner Eileen Gillese told the assembled family members and lawyers for 17 groups or organizations that having standing at the inquiry is an important part of public accountability.

"In many ways, this inquiry is about healing — healing our broken trust in the long-term care system," Gillese said.

"I most sincerely hope that through these public hearings, the Ontario public begins to feel heard and therefore begins to heal."

The inquiry is expected to last into September.