The criminal justice system is a crucial aspect of the Canadian legal system; however, it has limitations. A criminal proceeding is not equipped to examine root causes or outline possible corrective measures. This is well illustrated in the case involving the tragic murders and attempted murders of long-term care patients by Elizabeth Wettlaufer, a registered nurse, between 2007 and 2016. Wettlaufer knowingly and wrongfully injected 14 senior citizens with insulin, causing their death or injury. The case not only resulted in criminal proceedings, but also initiated a broad and in-depth public inquiry into the safety and security of residents in the long-term care home system. That inquiry (The Long-Term Care Homes Public Inquiry) started in August of 2017 and the final report and recommendations were released in July of this year. Even though the report was a mandate of the Government of Ontario, and reviewed some items specific to processes and reporting in Ontario, the bulk of the report was designed to have real relevance broadly for the long term care industry and health care in general. From a legal point of view, it also has value for those involved in or practicing administrative law.

The mandate of the inquiry and its resulting report was not only to inquire into the events which led to the murder and attempted murder of long term care patients, but to study the underlying factors and circumstances that allowed those events to occur. This entailed the review of the relevant policies, procedures, practises, and associated accountability and oversight mechanisms in the health care system. The offenses that Wettlaufer committed were not uncovered until Wettlaufer actually confessed and turned herself in, failing which they may never have been discovered. This accentuated the fact that a full end-to-end inquiry was needed to uncover and prevent possible repeat tragedies of the same type and to regain confidence in the system. The report led to a comprehensive list of recommendations (91 in total) that touched on all systemic aspects of the industry and included the involvement of numerous stakeholders and participants in health care. Interestingly, the report found no fault with, or failure of, any specific individual or organization in the system. Instead it put the full weight of its findings on systemic vulnerabilities and not on individual failures. It emphasized that even though the system was clearly strained, it was not broken and the recommendations could be built on the existing core foundations. 


The comprehensive recommendations presented were structured into four basic strategies that emphasized the areas of prevention, awareness, deterrence and detection, known in the report as PADD. While each component of PADD had its own form of relevance, all centered on the future avoidance of the calamity that had been caused by Wettlaufer. The report pointed out the specific systemic vulnerabilities and the required systemic responses and emphasized the need for multi-stakeholder cooperation in the implementation of the individual recommendations. The findings and recommendations are worthwhile for anyone involved in the system, no matter where your location in Canada, to review.


In the area of prevention, the report emphasized three core areas of attention for the Ministry of Long-Term Care:

  • it encouraged the creation of a new unit to focus on regulatory compliance and best practices;
  • it focused on items that assisted in addressing the issues of staff shortages and opportunities for advancement; and
  • it highly encouraged the use of new technology to uncover patterns and problems in the system.

The prevention recommendations then went on to touch on funding, nursing education and training, and importantly, the assessment and performance levels of long-term care homes.  


Regarding awareness, the report recommended direct involvement and leadership from the Office of the Chief Coroner and the Ontario Forensic Pathology Service.  It called on these entities to provide research, information dissemination, and support on a range of items to help all organizations involved in long-term care recognize the signs and symptoms that could prevent misdeeds such as those that occurred in the Wettlaufer case. In addition, the report provided a set of recommendations to the College of Nurses that concentrated on the investigation process, research, education and overall programs, policies and procedures.


The recommendations related to deterrence focused on making changes to medication management systems in long-term care homes, improving medication incident analysis, developing strategies for insulin overdoses, and increasing staffing levels. It is here that the report calls for a grant program to help homes establish the necessary technology, infrastructure, staffing, and screening strategies to bolster deterrence mechanisms and to specifically engage pharmacists and pharmacy technicians.


The findings in the report emphasize the need for the death investigation process related to long-term care incidents to be better positioned to detect deaths caused intentionally, in both a quantitative and qualitative way. This calls for the use of better patient death records and more sophisticated and in-depth use of data analytics models. It encourages the expanded use of electronic capture, storage, and analysis of complete sets of patient data related to death.

Stepping back a little, it is clear to see the value in a comprehensive review of a complex and evolving system. While brought on by the worst of events, the review provided a public forum to shine a light into certain areas of the healthcare system that help define the core values of safety and security for an aging population. It managed to bring together experts, stakeholders, and workers in the industry in a concerted effort to provide answers and a path forward. There remains real work ahead as the various groups now attempt to implement the findings in the report. For a system that is correctly defined as currently "under strain" the real challenge now is how to make the significant changes necessary to prevent further tragic events from occurring.  

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