Nursing Home Inquiry: Families of Murdered Seniors Blast “Systemic Failures”

Alex Roslin | September 25th, 2018

Photo: Maskot/Getty Images.

Family members of seniors murdered by nurse Elizabeth Wettlaufer are blasting “systemic failures” in Ontario’s long-term care system that let Wettlaufer get away with her killing spree.

Wettlaufer was able to murder eight seniors in her care and harm six others partly because of a “chronically underresourced” system, in which “many in positions of authority disregarded their obligations” under the law, the families said in their closing submission to a public inquiry this week.

“All of this led to repeated missed opportunities to uncover her wrongdoings,” the submission said. “Our seniors deserve better … Those who were involved in providing and regulating for each of the victims’ care collectively failed them.”

The inquiry, which started in June, is hearing final submissions from families, survivors, professional bodies and other participants this week.

With 30 per cent of Ontarians over age 85 living in long-term care and other seniors’ facilities, the inquiry is crucial for not only uncovering what went wrong with Wettlaufer, but also how to ensure all seniors remain safe and properly cared for, the families’ submission said.

“There are more people who are more vulnerable in long-term care now than there were at the time Ms. Wettlaufer was committing her offences,” their submission said.

Among the families’ concerns:

Staff levels in care facilities haven’t kept pace with the growing care needs of aging Ontarians. “Front line staff and managers alike complained about inadequate staffing levels,” the submission said.
The inquiry heard that Wettlaufer was able to get away with her crimes because she was often the only registered nurse on the night shift. In a prison interview with inquiry lawyers, Wettlaufer said frustration with overwork was one of the reasons she killed.
At one facility where she worked, only one registered nurse was responsible for up to 99 residents on the night shift. That worked out to a paltry 4.5 minutes with each resident in a shift — not enough for adequate care, the families’ submission said. “It is respectfully suggested that the average Ontarian would be shocked by that ratio,” they said.
The families express concern that the Wettlaufer inquiry has yet to focus on underfunding of long-term care homes. They call on the inquiry to look into the lack of funding in the next phase of its investigation. “The implications of chronic understaffing at long-term care homes are significant, and directly related to the mandate of the inquiry,” the submission said.
Wettlaufer was able to go undetected partly because medication wasn’t strictly controlled in nursing homes. (She killed seniors by injecting them with large doses of insulin, causing their blood sugar to drop.) It’s a widespread problem in care facilities. Over 40 per cent of care facilities weren’t complying with provincial medication management rules, according to 2017 inspections.
A lax provincial inspection system also contributed to Wettlaufer going unstopped for so long. The province doesn’t have enough inspectors to properly oversee facilities, the families said.
Nursing homes repeatedly failed to report problems with Wettlaufer’s nursing work as required by law. “Each of those moments provided important missed opportunities to place Ms. Wettlaufer’s conduct under scrutiny,” the submission said.
In fact, inadequate reporting of problems seems to be a widespread problem in nursing homes, but the rules “are not strictly enforced” by the province, the submission said. No one at a nursing home has ever been successfully prosecuted for a failure to report.
Oversight of homecare services for seniors seems to be even more lax, the submission said. Homecare nurses go virtually unsupervised, and “there is almost no chance of random spot checks” of their work. It’s a growing concern as the number of seniors getting homecare goes up. “We could be creating a similarly fertile ground for the abuse of our at-risk citizens,” the submission said.

After closing submissions this week, the inquiry will hold consultations with experts in coming weeks on how to improve care home safety. Final recommendations are expected in July 2019.

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