White Coat, Black Art

What families can learn from Wettlaufer inquiry into nursing home care

When former nurse Elizabeth Wettlaufer murdered vulnerable patients in Ontario nursing homes, she did more than leave a trail of shock and grief behind — she exposed serious cracks in the long-term care system.

The murder of vulnerable patients in Ontario exposed serious cracks in the long-term care system

Susan Horvath, daughter of Arpad Horvath Sr., one of former nurse Elizabeth Wettlaufer's victims, in June 2017. Despite the inquiry, Horvath said she worries nursing home businesses won't change. (Peter Power/Canadian Press)

When former nurse Elizabeth Wettlaufer murdered vulnerable patients in Ontario nursing homes, she did more than leave a trail of shock and grief behind — she exposed serious cracks in the long-term care system. 

Many of those deficiencies were revealed during the ongoing inquiry into Wettlaufer's actions, which this week heard closing submissions from her lone surviving victim and family members of other victims.

Wettlaufer pleaded guilty to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault. She was sentenced to life in prison for giving insulin to kill and injure those in her care in southwestern Ontario between 2007 and 2014.

The College of Nurses of Ontario took away her licence.

Such murders and injuries are rare, but how did the system allow a serial killer to work unimpeded for so long, and how does that lack of oversight harm other residents? CBC White Coat, Black Art host Dr. Brian Goldman explored those questions with Dian Shannon. She ran one of the homes where Wettlaufer worked and was a witness before the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System.

Nursing home challenges

As a former executive director at Telfer Place in Paris, Ont., Shannon said Wettlaufer was hired to fill in during staff shortages — a chronic challenge at many long-term care homes.

Recruiting and retaining staff was a major preoccupation for administrators because the work in nursing homes is difficult and pays less than in hospitals, Shannon said.

Lone surviving victim of serial killer nurse testifies

4 years ago
Duration 3:58
Beverly Bertram, the lone surviving victim of serial killer nurse Elizabeth Wettlaufer, made it clear she'll never forget what happened to her but could forgive Wettlaufer for what she did.

Caring and attentive staff were needed to help the 45 men and women at Telfer Place with dressing and using the toilet, meals and supervision with medication. Like many residents in long-term care, about 75 per cent had dementia.

After more than six months of casual work, Shannon said staff began complaining that Wettlaufer slept on the job, didn't help on rounds and skipped necessary paperwork. 

Ways to improve care

Wettlaufer confessed to police about giving Telfer Place resident Sandra (Sandy) Towler an overdose of insulin. Towler was saved when a nurse on the next shift recognized she had very low blood sugar and corrected it.

At the time, Shannon said the incident raised no red flags about Wettlaufer's deadly intent.

Former nursing home administrator Dian Shannon said she could see how a homicide could occur when a nurse works alone with easy access to medication. (Submitted by Martin Schwalbe/Dian Shannon)

"I didn't realize until I sat in the OPP interview that there'd been an attempt on Sandy," Shannon told Goldman. "I was horrified." 

Shannon said everyone at the nursing home "adored" Towler and her generous and affectionate personality. They couldn't believe Wettlaufer​ considered her disposable.

The inquiry's commissioner heard about how inadequacies in staffing and easy access to insulin — a potentially lethal medication — set the stage for problems to linger.

Long-term care generally faces low funding given the residents' needs, Shannon said. She fears recommendations from the inquiry will focus just on medication errors.

Elizabeth Wettlaufer worked at Telfer Place in Paris, Ont. in the spring of 2016. (Reveraliving.com)

"I think that if the inquiry comes out with a recommendation that nurses supervise each other when they're drawing up insulin … then I think we've missed the entire purpose of how do we care for people properly?" she said.

Lawyer shares 5 tips for relatives

The inquiry heard many examples of poor care and complacency, said Jane Meadus, a lawyer with the Advocacy Centre for the Elderly, a legal clinic that represents seniors. She attended most of the hearings on behalf of the Ontario Association of Residents' Councils, which represents nursing home residents.

Long-term care needs to provide good quality care, not just any care, said Jane Meadus. (CBC)

For Meadus, the "failures to report" were the main revelation of the inquiry. In some cases, nursing home staff reported Wettlaufer's mistakes to administrators, but the information wasn't passed on to the province's health ministry or nursing college, despite 2010 Ontario regulations meant to encourage the disclosures.

Shannon said she didn't consider Wettlaufer's laziness or the number of medication errors she made to be offences that needed to be reported to the province's nursing college.

Several medication errors weren't followed up on, not only by Wettlaufer but by others, Meadus said.

That's why Meadus encourages relatives of nursing home residents to:

  • Visit regularly and at different times of the day.
  • Advocate for your loved one.
  • Know your rights.
  • Look for potential medication errors, such as a drug cart that's left open with pills spilled — a sign to ask, "Did mom or dad actually get the medication?"
  • Read inspection reports in provinces where they're available.

When asked if a bad home is better than no home at all, Meadus replied: "I think we have to provide good quality care, not just any care."

'We the victims are not weak'

It's a sentiment shared by Wettlaufer's sole remaining survivor, Beverly Bertram. Bertram survived an overdose of insulin administered by Wettlaufer in 2016. This week, she told the inquiry her ordeal is not over.

"We the victims are not weak. We need care, and that doesn't mean we don't matter any more," Bertram, 70, said in her closing statement.

Susan Horvath's father, Arpad Horvath, was murdered by Wettlaufer at the Meadow Park nursing home in London, Ont. The family is suing the nursing home and other parties for $12.5 million.

"I'm breaking down," Horvath said in her closing submission. "With all this talking and caring and crying ... I'm asking myself is there ever really going to be a change or are these private business owners just worried more about the money?"

The inquiry's final report is due next July.