Wettlaufer inquiry reveals series of failures to protect elderly victims

An Ontario public inquiry looking into how Elizabeth Wettlaufer's crimes went undetected for a decade began hearing testimony this past week that warning signs about the nurse's conduct were repeatedly swept "under the table."

Elizabeth Wettlaufer murdered 8 elderly patients, yet her crimes went unnoticed for a decade

Elizabeth Wettlaufer, 58, is serving a life sentence for murdering eight patients and trying to kill or harm six others. (Dave Chidley/The Canadian Press)

A public inquiry looking into how Elizabeth Wettlaufer's crimes went undetected for a decade began hearing testimony this past week that warning signs about the nurse's conduct were repeatedly swept "under the table."

The crimes began in 2007 and continued to 2016 when Wettlaufer finally confessed to police. Until then, her employers, police and Ontario's licensing body for nurses had no idea eight patients had been murdered and six more poisoned —all with injections of massive doses of insulin.

"Why was she able to get away with this undetected?" asked Mark Zigler, the co-lead counsel for the public inquiry in St. Thomas, Ont., which will last four months and release its recommendations next summer.

Already, a series of startling revelations is highlighting how a health care system that was supposed to protect the elderly and vulnerable may have failed them.

Union protected Wettlaufer, witness testifies

The inquiry's first witness was Brenda Van Quaethem — the administrator at the Carressant Care long-term care facility in Woodstock, Ont. That's where Wettlaufer has since admitted to killing seven of her eight victims.

She detailed at least nine separate occasions where Wettlaufer was suspended or admonished for making medication errors, abusing a patient and staff.

But she accused Wettlaufer's union of making it difficult to sanction or terminate her because the Ontario Nurses Association would grieve her suspensions and terminations.

"It was cheaper," she said, not to fight the union. She pointed out that Carressant Care had to reimburse Wettlaufer for prior suspensions and pay $2,000 in "damages" when it finally terminated her employment in 2014.

The inquiry has heard that Carressant Care found it difficult to recruit and retain registered nurses due to nursing shortages.

Alex Van Kralingen, the lawyer representing four of the victim's families, calls the testimony troubling.

"A nurse who should not have been there, or who in any other circumstance may have been terminated much earlier, was allowed to stay simply because there were repercussions of not having any nurse there in the environment at the time," said Kralingen.

The inquiry was also told Carressant Care had increasing concerns about Wettlaufer. In August 2012, the home threatened to report her to the College of Nurses of Ontario for a "fitness to practise" hearing that could have put an end to Wettlaufer's career.

The facility didn't follow through.

Licensing body decided not to revoke Wettlaufer's licence

The College of Nurses of Ontario said Carressant Care had reported her termination to the licensing body in April 2014 — shortly after she was fired.

The college was also provided with a list of her transgressions.

Yet Wettlaufer's licence was neither suspended nor revoked.

Instead, she went on to find work at the Meadow Park care home in London, Ont., where she killed Arpad Horvath, 75. She also tried to kill two more patients while working for health care agencies in Ingersoll, Ont., and Paris, Ont.

Representatives of the union and college are expected to testify in the coming days and weeks.

James Lancing Silcox, Wettlaufer's first victim, is seen in this photo provided by his family. (Silcox family)

First death unexpected, but no autopsy

James Silcox, a Second World War veteran, was the first of Wettlaufer's victims. He was murdered at Carressant Care in 2007.  

Documents reveal the local coroner was advised his death was unexpected, yet no autopsy was performed that might have detected an insulin overdose.  

Silcox's daughter Andrea says the system failed all of the victims.

"This wasn't the fault of one person; this was the fault of the system," she told CBC News. 

"It wasn't just Wettlaufer that is to blame for this whole thing. She was given the opportunity to do these things by people brushing her previous issues under the table."

About the Author

John Lancaster

Senior Reporter, CBC Toronto

John Lancaster is a senior reporter with CBC News focusing on investigative and enterprise journalism. His stories have taken him across Canada, the US and the Caribbean. His reports have appeared on CBC Toronto, The National, CBC's Marketplace, The Fifth Estate-and of course CBC online and radio. Drop him a line anytime at