Ontario's chief coroner faces scrutiny at Wettlaufer inquiry

The province's chief coroner says some long-term care homes are still submitting death records by fax, instead of electronically, forcing a four-year delay in his office's planned data analysis.

Budget cuts meant deaths of people in long-term care not investigated unless 'unexpected'

The province's chief coroner says some long-term care homes are still submitting death records by fax, instead of electronically, forcing a four-year delay in his office's planned data analysis.

Dr. Dirk Huyer said his office has been ready to analyze deaths in long-term care homes since 2014, but hasn't been able to because death records are being sent in different formats. To analyze just the electronic records would lead to incomplete and incorrect data analysis, he said. 

"It defeats the purpose of an analytics model of trying to identify patterns," Huyer said.

It's unclear if such an analysis may have found a pattern of problems with patient deaths under nurse Elizabeth Wettlaufer's care. 

Wettlaufer admitted to killing eight patients in southwestern Ontario by injecting them with massive amounts of insulin. 

The Wettlaufer inquiry, which resumed Monday after a two-week break, is hearing from the coroner's office. It's trying to determine what systemic problems led to Wettlaufer being able to get away with the murders undetected.

$900K in savings

Huyer led the inquiry through the hierarchy within the coroner's office system, and what prompts death investigations. 

Prior to 1995, every death in long-term care homes was investigated by local coroners. In an effort to save money, the province cut that to every tenth death. 

Then, in 2013, to save $900,000, the province scrapped those investigations. Instead, nurses or doctors fill out a death record form. If a death is "sudden and unexpected," an investigation is started. 

Three of the deaths attributed to Wettlaufer were reported to a local coroner, the inquiry heard Monday. Of those, two led to investigations, but none led to autopsies that could have revealed the patients died of insulin overdoses.  

The inquiry also heard that coroners are doctors who take a five-day course. They get paid $450 for every death investigation they complete. 

'Shocking revelations'

The public inquiry into long-term care has now shifted from the state of nursing homes where ex-nurse Wettlaufer was able to go on killing patients undetected — to other agencies and groups that could have flagged her crimes. 

Wettlaufer murdered eight people with insulin overdoses and tried to kill six others while working in long-term care facilities in southwestern Ontario. In 2016, she checked herself into a mental health hospital and confessed to her crimes. 

The inquiry is taking place at the Elgin County courthouse in St. Thomas, Ont., and is expected to last until September. 

In advance of Monday's resumption, CBC News spoke with lawyer Alex Van Kralingen, who represents the families of some of Wettlaufer's victims, about what the inquiry has heard so far and what to expect moving forward: 

What have you heard that has shocked you the most? 

There's been a number of shocking revelations. The long-term care industry is highly regulated and contemplates the circumstances when the Ministry of Health needs to be called in, including different kinds of medication errors and abuse of residents. The purpose of these regulations to make sure there is an external check to protect vulnerable residents in long-term care facilities. But if those who run the facilities don't understand or don't know the obligations or ignore the obligations, then a crucial safeguard for residents is being lost and unfortunately that appears to have been the case in a number of points.

Similarly, there are obligations to report to the College of Nurses, but we've learned that those in the administration of the homes in question simply didn't understand or ignored those allegations as well. 

For me, the most troubling fact was that on the day that Ms. Wettlaufer was fired from Caressant Care (in Woodstock, Ont.), all the senior management at Caressant Care had an email exchange where they said that she was a very dangerous nurse, and on the stand the vice-president of operations clearly told me that she was a danger to any resident where she subsequently worked. But if you look at their conduct, it doesn't seem like they acted with any kind of urgency.

It took them three weeks to write a letter to the College of Nurses, which appears to have been sent by regular mail, by that time Ms. Wettlaufer had a new job, and there was subsequently a reference letter, indicating that the organization was pleased to provide her with a reference, which Ms. Wettlaufer actually used during her probation period at Meadow Park (in London, Ont.) to give Meadow Park some comfort that there wasn't a problem with her nursing skills or the way she conducted herself with residents. That's troubling and it's troubled my clients.

How have your clients responded to that revelation and others that have come out?

They're obviously dealing with a lot of trauma associated with Ms. Wettlaufer's crimes, and as you can appreciate having to relive it again has been really painful.
Toronto lawyer Alex Van Kralingen is representing five people who are either family or 'close loved ones' of the eight seniors who were killed by Elizabeth Wettlaufer. (Van Kralingen and Keenberg LLP)

One of the great frustrations right now is that in the context of a public inquiry, where the purpose is to learn from our collective failures, it seems that everyone is pointing fingers at each other and not appreciating that everyone could have done much better. So, if the ultimate point of the exercise is creating policies which are aimed at avoiding these kinds of crimes from happening again, those responsible are going to have to own up to their failings and more importantly, collaborate to make sure this doesn't happen again.

What can we expect from this next phase of the inquiry?

In the next four weeks, the focus changes from the facilities. We start to look at the coroner's office, how they operated and how they managed the deaths of Ms. Wettlaufer's victims for which they were called, in particular the decision of why to conduct or not to conduct a death investigation in any given circumstances. We're also going to look at the policy work being done at the coroner's office regarding geriatric care and the circumstances where you conduct a death investigation. 

Then, we're going to switch to the College of Nurses and better understand the information they had and what they acted upon and if the quality of their processes and investigations could be improved.

Finally, the last two weeks will look at the role of the Ministry of Health and Long-term Care, questions surrounding funding, their oversight responsibilities and instances where they may have fallen short. The real question for me during the ministry portion is, if the oversight of these homes appears to have been prompted based on some self-reporting scheme, what happens when homes don't self-report for some reason. What other fail-safes are there to ensure that the ministry can keep its obligations to keep residents in long-term care facilities safe.

What's the main question for the provincial coroner? 

There's been a real shift in education about these issues, but it appears that at the time of this, the local coroners who were involved, all they required was a three-day course, and I'm not sure what kind of continuing education they required. That's going to be a focus of my questioning because I think we need to be doing much better, particularly when you have a vulnerable population that is susceptible to a killer like Elizabeth Wettlaufer who was trying to use surreptitious means to get away with her murders.

After hearing what you've heard so far, what should people take away from long-term care in this province? 

There are some encouraging aspects and discouraging aspects.

Whenever we had someone who was on the front line, PSW, or an RP or RN, I truly felt these were people who were really, really dedicated. They care about their residents. I'm convinced they care about their residents. 

The challenge that all they articulated that I hope this inquiry is a springboard into — they're all incredibly stretched. It just seems to be casually accepted that these homes are short-staffed and the staff who work there are under incredible amounts of stress in terms of their workload. We've heard a lot about how it's physical work and mentally taxing work, and that's because of the tight funding envelopes that these facilities get from the ministry of long-term care.

About the Author

Kate Dubinski


Kate Dubinski is a radio and digital reporter with CBC News in London, Ont. You can email her at