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Systemic problems still exist in long-term care, Wettlaufer inquiry hears

At least two systemic failures that allowed serial killer Elizabeth Wettlaufer access to vulnerable elderly patients haven't been fixed in the two years since she confessed to eight murders, a public inquiry heard Thursday.

Elizabeth Wettluafer tried to kill a 68-year-old home care patient by putting insulin in her PICC line

At least two systemic failures that allowed serial killer Elizabeth Wettlaufer access to vulnerable elderly patients haven't been fixed in the two years since she confessed to eight murders, a public inquiry heard Thursday.

The Ontario College of Nurses doesn't note on its website if it's investigating a nurse, a practice that has put nurses who eventually get reprimanded into the homes of vulnerable patients, the inquiry heard. 

St. Elizabeth Home Health Care, which relied on online written references to provide Wettlaufer a job that allowed her access to an elderly patient she tried to kill, still doesn't contact references directly.  

"Why would we call them? Our online tool is quite extensive," said Patricia Malone, the company's corporate integrity officer. "What are we going to learn from a phone call?" 

The inquiry is being held at the Elgin County courthouse in St. Thomas, Ont. The first phase focused on facilities and agencies involved with Wettlaufer.

The inquiry will now take a break until July 16, when it will begin hearing evidence about the office of the coroner and the Ontario Forensic Pathology Service. 

Investigations take months

Malone said in the last year and a half, St. Elizabeth hired a nurse because her record on the College of Nurses of Ontario website, called Find a Nurse, appeared clear and indicated she could practice "without restrictions." 

But six months into the job visiting client homes, St. Elizabeth learned the nurse was under investigation and the college was moving to restrict the nurse's ability to work alone in people's homes, Malone said. 

"You hire them and you find out six months later that there was an investigation going on," she said. "In that case, that person would be out visiting clients in their homes." 

Others who have testified also said it would have been helpful to know if a nurse is being investigated, or if she or he was fired from a previous position, and for what. 

Wettlaufer was fired from her first job, in 1995, for stealing narcotics and overdosing while on shift. She was also fired from Caressant Care in Woodstock, Ont., in 2014 for making multiple medication errors. 

None of that history was noted on her College of Nurses page, searchable by the public and employers. 

Hiring practices under fire

St. Elizabeth health care also took heat on Thursday. 

The company uses an online portal that references fill out. When Wettlaufer was hired, comments made about a potential employee were anonymous to promote candour. Since then, the comments are no longer anonymous, and hiring managers now get training on how to interview and hire. 

But references are still not contacted, and although employers are told to look for red flags, they're not told what might constitute a red flag, Malone admitted. 

Earlier in the day, the manager who hired Wettlaufer in July 2016 testified. 

Wettlaufer had applied to St. Elizabeth in 2014 but wasn't hired because another nurse who'd previously worked at Caressant Care warned managers she didn't get along with staff and that she left under mysterious circumstances. 

When she reapplied in July 2016, she was asked by hiring manager Tamara Condy about the situation at Caressant Care. Wettlaufer admitted to making a medication error and being fired but said she'd been cleared. 

She was hired. 

There were immediate problems with Wettlaufer. She had trouble changing the dressing on a PICC line, which she would be required to do for some home-care clients. 

A PICC line is an IV that stays in place indefinitely so drugs can be administered over a prolonged period of time.

Wettlaufer needed certification to change the PICC line. To get certification, she had to satisfactorily perform the procedure twice. 

She was "resistant to coaching" from a supervisor, Condy said, so she was sent to preform the procedure with a nurse known for her expertise in PICC lines. 

Again, Wettlaufer couldn't perform the task. She used improper sterilization techniques, Condy said. 

Condy went out with Wettlaufer herself and watched her perform a PICC line change, which Wettluafer botched. 

Despite that, Condy certified her. 
The letter Elizabeth Wettlaufer left for her boss in August 2016, just weeks before she was to start working with diabetic children.

Less than two months into the job, Wettlaufer abruptly quit, leaving behind her equipment and a resignation letter. 

She later told police she had quit because she was going to have to work with diabetic children, and she didn't trust herself not to hurt them. 

Inquiry runs until fall

The Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System is in its fourth week.

The inquiry was established on Aug. 1, 2017, after Wettlaufer was sentenced to eight concurrent life terms. It began hearings on June 5, and is examining how Wettlaufer's crimes went undetected for so long.

Wettlaufer confessed to a psychiatrist at the Centre for Addiction and Mental Health in Toronto, in September 2016, that she injected people with insulin between 2007 and 2016, killing eight and harming six.

Until her confession to a psychiatrist and social worker, her employers, police and Ontario's licensing body for nurses had no idea eight patients had been murdered and six more poisoned with injections of massive doses of insulin.

The inquiry is scheduled to last until September.

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