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New provincial inspection system didn't catch serial killer, Wettlaufer inquiry hears

Ontario's Ministry of Health and Long-Term Care relies on nursing homes to self-report high-risk incidents and deal quickly with complaints, which then determines how much scrutiny those facilities face from provincial inspectors, the Wettlaufer inquiry heard on Monday.

Revamped system was supposed to bring more rigour to nursing home facilities

Ontario's Ministry of Health and Long-Term Care relies on nursing homes to self-report high-risk incidents and deal quickly with complaints, which then determines how much scrutiny those facilities face from provincial inspectors, the Wettlaufer inquiry heard on Monday. 

"Our inspection program is based on the information we get. That's why it's so critical for them to report," said Karen Simpson, who until recently was the director of the long-term care inspections branch with the ministry. 

"Those staff — none of those people working alongside Elizabeth Wettlaufer — knew what she was doing. Given that those staff who were working alongside her had no idea, our inspectors certainly wouldn't have been able to find that." 

Wettlaufer killed eight patients and harmed six others while working as a nurse in long-term care homes from 2007 until she confessed in 2016.

An overview of the long-term care sector in Ontario provided at the Wettlaufer inquiry. (Supplied)

The nursing home inspection system was designed to increase inspection powers and to put a sharper focus on residents' rights and safety, Simpson testified at the Elgin County courthouse in St. Thomas, Ont., where the inquiry is being held.

"If the families and if the residents and if the staff aren't identifying those concerns, then we're not going to go down that road. We're like the police. They don't conduct prospective investigations, they get tips that lead them to investigate. And we need tips, too," she said.  

Simpson is the first official with the ministry to testify this week at the inquiry into the safety and security of residents in long-term care. 

The inquiry will hear this week and next from several inspectors who investigated three long-term care facilities in Ontario after Wettlaufer's crimes came to light:

  • Caressant Care in Woodstock.
  • Meadow Park in London.
  • Telfer Place in Paris. 

Regulation changes in 2010

In 2010, the ministry of health rolled out its new Long-Term Care Homes Act, replacing the Nursing Homes Act. 

The new act placed a greater focus on patient safety and spelled out mandatory reporting guidelines for long-term care homes. It also changed the role of provincial "compliance advisers," who collaboratively worked with nursing homes to minimize risk to "inspectors" who ordered the facilities to act. 

The new system brought with it what were supposed to be comprehensive annual inspections, which included a four-inspector team going into nursing homes and interviewing residents, family members, staffers and going through documentation, Simpson said. 

The province didn't hire any new inspectors until 2013, delaying the rollout of the annual inspections. 

When they did begin in 2014, they were taking too long, Simpson said. So, the province divided homes into three levels. Those levels dictated how much scrutiny a home was put under. 

Level 1 homes were inspected by two inspectors over five days. Level 2 and 3 homes were inspected by three inspectors over 10 days. 

But Simpson admitted that if a home didn't self-report problems, it would face less scrutiny. 

After Wettlaufer confessed to killing patients, the ministry looked at the levels of each of the three homes where she worked. Each had dipped to a Level 2 home, therefore requiring more scrutiny, but Wettlaufer's crimes were not discovered. 

Simpson said some critical incidents at Caressant Care were not reported to the ministry when they should have been, making it difficult for inspectors to see a pattern. 

The inquiry is expected to last until September. 

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