Lack of insulin tracking at home where Wettlaufer worked allowed for abuse, inquiry hears

Insulin was easily accessible to nursing staff at Meadow Park Long-Term Care in London, Ont., where killer nurse Elizabeth Wettlaufer found her last victim, the home's former co-director of care testified Wednesday.

Elizabeth Wettlaufer killed 8 elderly patients in her care by giving them insulin overdoses

Melanie Smith was the co-director of care at Meadow Park in London, Ont. (Kate Dubinski/CBC News)

Insulin was easily accessible to nursing staff at Meadow Park Long-Term Care in London, Ont., where killer nurse Elizabeth Wettlaufer found her last victim, the home's former co-director of care testified Wednesday. 

And nurses were free to administer insulin without a double-check by a colleague, because the layout of the home made it impractical for two people to do so, Melanie Smith told the public inquiry into resident safety at long-term care homes. 

"You don't draw up the insulin ahead of time, you do it right before you administer it, so it wouldn't be practical [to have two nurses do that]," Smith said. 

No one double-checks that a patient is given a correct dosage of insulin or the correct amount, she said. 

Smith worked at Meadow Park at the same time as Wettlaufer, who confessed to killing eight people, including one at Meadow Park, by injecting them with insulin. 

But Smith said she had no problems with Wettlaufer's nursing abilities. She said she was a "jovial person" who lacked confidence. 

Wettlaufer quit her job abruptly in September 2014, saying she had a health issue she needed to take care of that prevented her from nursing. 

She told the home's director of care Heather Nicholas she was addicted to drugs and alcohol. She was also suspected of stealing narcotics on her last day, but was not reported to the Ontario College of Nurses because she'd already quit. 

None of the information about her addiction, or the fact that she had a health issue that would prevent her from working, was passed on to Smith. 

Proper abuse reports not filed

The inquiry is being held at the Elgin County courthouse in St. Thomas.

The inquiry also heard about an incident on Aug. 10, 2014, involving resident Arpad Horvath, 75, at Meadow Park. 

​Horvath was found with the drawstring of his pants wrapped around his bedrail and tied in a tight knot. But Horvath was unable to use one of his hands, making the tying of a knot virtually impossible. 

Wettlaufer reported the incident in her nursing notes about Horvath.

In retrospect, the incident should have been reported to the Ontario Ministry of Health and Long-Term Care as possible abuse, Smith admitted. It was not reported. 

"That's the first time I heard anything about tying [him] … to the bed. I was shocked. I hadn't heard about it," said Susan Horvath, the resident's daughter, outside the court. 

"They're supposed to keep you informed when you have someone in there."

On Aug. 31, 2014, Wettlaufer injected Horvath with a high dose of insulin which killed him. He is her last known victim.

Union sought $10K settlement

Later Wednesday, the inquiry also heard from Wanda Sanginesi, the vice-president of human resources at the Caressant Care home in Woodstock, Ont., where Wettlaufer killed seven patients.

She was fired by Caressant in March 2014 after committing 12 errors related to her duties, including the administration of medication.

During negotiations around her termination, Sanginesi said the Ontario Nurses Association (ONA) had asked for a settlement of $10,542, equal to one week per year of service.

The ONA also asked Caressant Care to provide Wettlaufer with a reference letter that "commented in a positive way" about Wettlaufer's skills.

The ONA also sought to have Wettlaufer's personnel file at Caressant sealed.

In the end, Caressant Care agreed to pay Wettlaufer a $2,000 settlement and provided her a reference letter that included only details about her employment there.

Caressant Care did not share any information with other long-term care facilities about Wettlaufer's performance and eventual termination.

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

Her killing spree began in 2007 and continued until 2016, when she finally confessed to a psychiatrist and a social worker. Until then, 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.