Updates from the Long-Term Care Homes Public Inquiry

October 1, 2018

The Ontario Nurses’ Association (ONA) is participating in the Public Inquiry into Long-Term Care. ONA has signaled that it is participating in order to ensure that a tragedy like the Elizabeth Wettlaufer case never again occurs. ONA will post updates on the proceedings regularly.

September 24 to 26, 2018: Closing Statements

From September 24 to 26, 2018, the Inquiry heard closing statements from the parties.

On September 24, the Inquiry heard from the victims and their families. The statements were powerful reminders of the heartbreak that Elizabeth Wettlaufer left in her wake. The victims and their families also passionately recommended changes to the long-term care system, with many mentioning the need for more staff and funding.

Following their statements, the Inquiry heard from all the Participating Parties who also put forward recommendations to ensure that the circumstances that permitted Elizabeth Wettlaufer to commit her crimes undetected over a seven-year period never reoccur.

There was consensus on many of the systemic problems in long-term care:

  • Staffing levels are unacceptable and must be increased in order to meet the increasing acuity and care needs of residents.
  • In order to increase staffing, changes to funding in long-term care will be required.
  • Retention and recruitment of qualified Registered Nurses must be addressed.
  • Medication management systems need to be more robust.
  • Training is required to ensure an understanding of reporting requirements to the Ministry of Health and Long-Term Care, as well as the College of Nurses of Ontario.

Although there was not always agreement on the solutions to the above-listed problems, there was agreement that in order to recruit and retain RNs into long-term care, there needs to be wage parity for nurses in the various sectors:  nurses in long-term care should be paid the same as those working in hospitals, including benefits and pension portability.

This is encouraging, as it is the first time that representatives from the employer agreed that wage disparity was impacting on their ability to recruit nurses into the sector.

ONA Recommendations:

ONA made a number of recommendations, including:

  • That the Ministry of Health and Long-Term Care immediately increase funding to the long-term care and that funding reflect the actual needs of residents.
  • That for-profit long-term care homes be phased out and replaced by non-profit homes.
  • That a nurse-to-resident ratio be set at 1:20.
  • Agency use must be eliminated, or in the alternative, the Ministry of Health and Long-Term Care be given oversight of these agencies.
  • RNs be given wage parity with nurses working in the hospital sector.
  • Colleges and universities should provide more education on gerontology and senior care and a clinical placement in long-term care should be mandatory.
  • Mandatory training for administrators and Directors of Nursing on reporting obligations related to fitness to practice to the College of Nurses of Ontario, as well as to Human Rights, employer obligations and privacy legislation.
  • That whistle-blower protection be enhanced.
  • That home care be appropriately funded.

ONA addressed in its written and oral submissions the allegations that the Union may have, in some way, facilitated Wettlaufer finding employment following her termination from Caressant Care Woodstock. However, the evidence demonstrated that the reference letter, which was written by Caressant Care Woodstock, played no role in Ms. Wettlaufer’s hiring by Meadow Park, Lifeguard or St. Elizabeth Health Care. In fact, Ms. Wettlaufer was hired by all three after received a “glowing” verbal reference from the Assistant Director of Nursing at Caressant Care Woodstock. ONA noted that the only party who held all the relevant information about Ms. Wettlaufer’s work history was Caressant Care Woodstock; ONA was provided with only a fraction of the overall disciplinary record.

Notwithstanding the evidence, many parties made recommendations regarding a union’s ability to negotiate reference letters as part of the grievance process. Counsel for the Participating Employers also recommended that the government provide them with additional funding specifically to fight grievances at arbitration so that they wouldn’t have to settle them.

ONA disagrees with these recommendations. Funding from the “other accommodation” envelope is to cover the costs associated with labour arbitration. As legal counsel for the Ontario Association of Resident Councils noted, the employer had an option: they were not forced into resolving the grievance, which had not even been referred to arbitration.

What’s Next?

With the public hearing phase concluded, the Inquiry is now moving into the next phase of consultations.

The Commissioner will be meeting individually with various stakeholders, including ONA.  There will then be a “mini-plenary” session and a “full plenary” session, held in November and January respectively, at which time further discussions will occur about possible recommendations.

The final report will be issued July 31, 2019.

ONA looks forward to continuing to participate in the Inquiry.

September 12, 2018

The Long-Term Care Inquiry resumed on September 12, 2018, in order to hear expert and technical evidence.

The first expert to testify was Beatrice Crofts Yorker, who is qualified as an expert on health-care serial killers (“HCSK”). Professor Yorker has conducted extensive research into the phenomenon of HCSK. She testified that Canada has only had two cases: the suspected murders at the Hospital for Sick Children in the 1980s, for which no one was convicted, and the Wettlaufer murders. Internationally, she found more than 131 prosecutions in 25 countries dating back to the 1970s.

Professor Yorker noted several common themes in many of these cases:  they selected victims from a vulnerable population and often used injectable medications as their weapon, with insulin being the most common.

While the majority of murders occurred in hospitals, Professor Yorker testified that there has been an increase in the numbers occurring in long term care settings. She attributes this partially to the fact that many hospitals have medication management systems in place.

Most importantly, when asked for her opinion on what could be done prevent or detect health care murders, she focused on staffing. Professor Yorker relied on very credible research that showed that patient outcomes improve when nurses are better educated and staffing ratios are higher. She also pointed to robust medication management systems, although she acknowledged that insulin is particularly problematic to track, especially in long-term care where it is routinely used for approximately one-third of the residents.

The second expert witness was Julie Greenall, who is a pharmacist and the Director of Projects and Education for the Institute of Safe Medication Practices, Canada (“ISMP”).

Ms. Greenall provided the Inquiry with thoughtful opinions on what steps could be taken to deter and detect murders in long-term care. She recommended that a number of steps could be taken to reduce the potential for intentional harm from insulin misuse, including:

  1. Limiting the supply of insulin per resident to a current pen and a spare pen, or a maximum 10-day supply based on usage.
  2. Implementing a central supply process for replacement insulin pens in long-term care homes.
  3. Developing standard audit processes to check the drug record book for unusual patterns of use.

Ms. Greenall also provided some recommendations on measures to detect whether a patient was intentionally harmed by the misuse of insulin:

  1. Evaluation of sudden changes in resident condition, specifically hypoglycemia. This includes prompt evaluation and investigation of possible causes in order to mitigate harm and protocols to routinely check blood sugar when a resident is found with a decreased level of consciousness or other signs of hypoglycemia.
  2. Review of the use of rescue medications, specifically glucagon.

She also recommended double checks of insulin as a best practice, though she acknowledged that this wouldn’t have stopped someone like Elizabeth Wettlaufer, who was surreptitiously administering insulin to residents.

Ms. Greenall also agreed that enhanced staffing would help with the detection and deterrence of intentional harm by health-care professionals.

The final witness was Dr. Michael Hillmer, the Executive Director of Information Management, Data and Analytics within the Health System Information Management Division at the Ministry of Health and Long-Term Care.

Following Ms. Wettlaufer’s confessions, Dr. Hillmer developed an analytical tool to determine whether the murders could have been detected earlier by comparing the expected number of deaths with the actual number (or observed number) of deaths in a long-term care home.

He determined that Caressant Care Woodstock was in the top 10 per cent of homes with the number of observed deaths exceeding the expected number of deaths, but that the tool would not have been able to detect the crimes, largely because they were spread out over a number of years.

Dr. Hillmer was the final witness. The Inquiry recessed until September 24, 2018, at which time the Participating Parties will provide their oral submissions and proposed recommendations.

September 21, 2018: Statement from the Ontario Nurses' Association regarding the Long-Term Care Inquiry

August 9, 2018

Mr. Steven Carswell completed his evidence on August 9, 2018.

After describing the general process for reviewing and investigating complaints about either the CCAC (now LHIN) or Service Provider Organizations, he then testified about his role in the Elizabeth Wettlaufer investigation.

Mr. Carswell testified that he learned about her confession on October 21, 2016. At that time, he was provided with only limited information from St. Elizabeth’s and had no idea of the scope of Ms. Wettlaufer’s crimes.

On October 25, Ms. Wettlaufer was charged with murder and attempted murder. Much of his knowledge of this case came from the media.

Ms. Carswell testified that he met with senior management at St. Elizabeth's. He testified that Michelle McKellar, a regional manager of contract management at the CCAC, was assigned to reach out to all the service provider organizations to ensure that Ms. Wettlaufer had not worked for them, or for any subcontractor. Ms. McKellar also reached out to the HNHB CCAC to ensure that none of the service providers and their subcontractors had a connection to Ms. Wetllaufer.

At the CCAC itself, the files for all patients who had been seen by Ms. Wettlaufer were reviewed. No further issues were identified.

Mr. Carswell testified that the SW LHIN had not learned, prior to the testimony of Tamara Condy at the Inquiry, that Ms. Wettlaufer had broken into a client’s house and stolen insulin that she then used in her attempted murder of Beverly Bertram. He indicated that this is something that should have been reported to the CCAC immediately once St. Elizabeth’s had learned of this information from the police.

Following Mr. Carswell’s testimony, the Inquiry adjourned until September 12, when evidence from two expert witnesses will be heard. Closing submissions are scheduled to commence on September 24, 2018.

August 8, 2018

ONA cross-examined Karin Fairchild on August 8. She confirmed that she had been involved in developing the new legislative and regulatory regime under the Long-Term Care Homes Act (LTCHA), with the exception of funding models. Ms. Fairchild also confirmed that in drafting the new legislation, she did not consider funding at all.

Counsel for ONA raised with Ms. Fairchild a series of reports and recommendations, including the following reports:

  • 2001 Price Waterhouse Cooper report finding that the overall hours of nursing care in Ontario is less than that in other jurisdictions and the proportion of care that is provided by registered nurses is less than in other jurisdictions.
  • The 2004 report by Monique Smith that has been described as the “blueprint” for the new LTCHA. In that report, Ms. Smith noted that many homes faced “challenging staffing issues” and gave as an example a 160-bed home staffed at nights with one RN, one RPN and four PSWs. The registered staffing level of one RN and one RPN is identical to that at Caressant Care Woodstock, which has 163 beds.
  • The 2006 Recommendations from the Coroner’s Inquest into the deaths at Casa Verde, which contained numerous recommendations aimed to improve staffing and funding of long-term care, including the recommendation for wage and benefit parity for nurses in long-term care and hospitals.
  • The 2008 Shirlee Sharkey report, which recommended that in order to ensure resident well-being and safety, the province should commit to four hours of direct care per resident including one hour of care from licensed nurses.
  • The 2012 Gail Donner report, which was described as an action plan to prevent abuse and neglect in long-term care. In addition to raising concerns about the disparity in wages for long-term care nurses, Ms. Donner also found that four of the top five causes of abuse and neglect centered around staffing issues, including workload, turnover of staff and insufficient numbers of staff.
  • The 2017 recommendation from the Geriatric Long-Term Care Review Committee which included a recommendation that the Ministry of Health should consider increasing staffing level requirements in long-term care settings given the high prevalence of dementia patients with psychosis.

Ms. Fairchild testified that the staffing and retention and recruitment challenges identified in those reports remains a concern. She agreed that because wages were higher in the hospital sector and municipal homes, retention remained problematic.

She was pushed as to why the Ministry required only one RN to be in a home 24/7, irrespective of the size of the facility.  She was asked why, when all the reports identify staffing as an issue, the ministry would not legislate one hour of nursing care per resident and/or more than one registered nurse depending on the size of the home. Ultimately, she stated that, “I’m not the person to make those decisions.  I would be happy for someone to make decisions at a higher level to fund those recommendations but I don’t have control over that.”

Following Ms. Fairchild’s testimony, the Inquiry moved on to hear evidence about home care in the province.

Donna Ladouceur testified from the South West LHIN about the role of the CCAC (and now the LHIN) in the provision of home care services. She described the role of Care Coordinators at the LHIN. She also testified about the contracts with the various Service Provider Organizations, such as St. Elizabeth’s, who provide the care in the home setting.

Ms. Ladouceur noted that staffing was also an issue in home care, that nurses work in isolation and in settings that are unpredictable and at times dangerous. She also testified to the rising acuity of home-care patients and confirmed that nurses working in home care are paid much less than in other sectors.

The final witness was Steven Carswell, the Vice President of Quality and Patient Experience at the SW LHIN. Mr. Carswell testified regarding the contracts between the SW LHIN and the service provider organizations and described how complaints are handled at the organization.

August 7, 2018

On August 7, 2018, the Inquiry heard from Phil Moorman, an Appeals Specialist and Programs consultant with the Long-Term Care Homes Inspections Division of the Ministry of Health and Long-Term Care.

Mr. Moorman testified about the Long-Term Care Quality Performance Assessment Tool, (“LPA”). This tool divides homes into four levels based on the ministry’s calculation of their level of risk:

  • Level 1 homes are considered to be in good standing and substantially in compliance with the regulations.
  • Level 2 homes need improvement due to a moderate risk level to residents.
  • Level 3 homes represent a high risk level to residents and require significant improvement.
  • Level 4 homes are those whose licenses have been revoked. These ratings are publically available on the ministry website.

The ratings are also used to determine the intensity of the annual inspection: Level 1 homes receive a briefer, “risk-focused” inspection, whereas Level 2 and 3 homes receive the full intensive inspection.

Mr. Moorman was questioned about the elements considered in creating the ratings, and testified that there were some weaknesses to the model. For example, the model considers findings of non-compliance in response to critical incident reports and complaints.  If reports and complaints are not received, then issues in the home may escape notice.

The second witness was Karin Fairchild, who is the Manager of Compliance Inspection at the ministry’s Hamilton Service Area Office. She was an important witness, as she had served as a Senior Policy Advisor during the time that the Long-Term Care Homes Act and its regulations were drafted. Ms. Fairchild provided support to Monique Smith during her review of long-term care and then helped draft the new legislation and regulations.

Ms. Fairchild testified about her role, advising that she was involved in all parts of the development of the new legislation and regulations, with the exception of funding models.

She indicated that she believed that all homes needed to have, at a minimum, an RN on duty 24 hours a day, seven days a week, who is a member of the regular nursing staff, regardless of the number of beds in the home, so that someone can always respond to a crisis situation.

She stated that RPNs are valuable but cannot fully replace all the functions performed by RNs, who have more education and deeper training in managing complex and emergent situations, provide risk management, clinical judgment and greater responsibility for facility management.

She also testified that she felt that there should be two teams of inspectors: one team to conduct the annual inspections and one team to conduct inspections in response to reports and complaints. She felt that the resources available to conduct all the reactive and proactive inspections were insufficient to meet the demand.

In cross-examination, Ms. Fairchild was asked whether she believed that long-term care homes were understaffed. While she vacillated on her response, she did say that whenever she was asked about what long-term care homes need, she would always say more staff.

Ms. Fairchild’s cross-examination will continue on August 8, 2018.

August 3, 2018

On August 3, 2018, Natalie Moroney completed her testimony.  She underwent a vigorous cross-examination by counsel for Meadow Park, focusing in particular on the rights of employees to have a lawyer present in their interviews.

Ms. Moroney was also asked about whether there was an appearance of bias in her inspection of Meadow Park, given that she had been the Director of Care at Meadow Park in 2008. She admitted there could be such an appearance, but that there had been complete turnover not only of management in the eight years since she had left, but also of all the registered staff and half of the Personal Support Workers. This demonstrates the retention problem in long-term care homes: of the three RNs and 11 RPNs interviewed during the inspection process, none had been at the Home for more than eight years.

The next witness was Lisa Vink, the Inspector assigned to lead the investigation following Ms. Wettlaufer’s confession at Telfer Place. Ms. Vink has been an inspector since 2000, and was able to give evidence about inspections under the Nursing Homes Act, when inspectors were assigned to specific Homes and could provide the Homes with advice and the current process under the LTCHA.

Ms. Vink described that the Telfer Place inspection raised issues different from that at Caressant Care Woodstock and Meadow Park because Ms. Wettlaufer had worked at the Home as an agency nurse.  As such, she was required to look at whether or not the Home had met the requirement under s.8 to have an RN who was a regular employee in the Home at all times, subject to an exemption permitting the use of agency nurses in emergencies.

Ms. Vink issued six written notifications, all of which were accompanied by Voluntary Plans of Correction. These findings of non-compliance included a failure to ensure that there was at least one RN who is an employee of the licensee and a member of the regular nursing staff on duty and present at all times.  She found that this happened on approximately 25 occasions.

She concluded her direct testimony noting that Ms. Wettlaufer’s crimes have impacted how people look at nurses and long-term care. She was tearful in commenting about Ms. Wettlaufer having abused her position of power to harm a vulnerable population.

In cross-examination, Ms. Vink described the “emergency” exception to the 24/7 requirement. She looked at the regulation, which stipulates that an agency nurse could be used if the emergency is unforeseen, an emergency and serious.

As an example, she indicated that if an RN called in sick, saying she had just fallen, broken her ankle and needed surgery that day, the Home could use an agency nurse, because the situation fit the definition of emergency in the regulation.  However, if that same nurse could not work the next day, it would not be an emergency, because it was no longer unforeseen.

The Inquiry adjourned and will resume on August 7, 2018.

August 2, 2018

On August 2, 2018, the Inquiry heard from three witnesses: Rhonda Kukoly, Carol Hepting and Natalie Moroney.

Ministry of Health and Long-Term Care Inspector Rhonda Kukoly was cross-examined by the parties in the morning. She confirmed that her role as an inspector is to ensure compliance with the legislation and regulations.

With respect to RN staffing, Ms. Kukoly testified that her role was to look for compliance with Section 8 of the Act, meaning that there was at least one RN in the Home at all times. If a Home is compliant, she does not look further: She does not look to see what the Home does to ensure compliance. For example, an inspector is not concerned with whether nurses are working doubles or, as heard in this Inquiry, even triple shifts.

She did testify that if there was an adverse impact on a resident such as a medical error leading to hospitalization with a significant change in condition, an inspector might consider staffing levels, but could not issue an order requiring the Home to staff the Home differently.

She also testified that when she finds agency nurses have been used that she will check to see when they were booked to make sure the booking fit within the provisions of the emergency exception in the regulation. Ms. Kukoly also testified that she felt that the Inspection Department was not sufficiently staffed to meet their goals under the Act.

The next witness was Carol Hepting, Vice President of Operations for Caressant Care Woodstock, who was recalled to be cross-examined by two parties about the Ministry inspections. She was asked about the Home’s inability during 2016-2017 to come into compliance following the issuance of numerous non-compliance orders.

Ms. Hepting indicated that they were trying their best, noting that prior to the confessions, the Home had been considered a well-functioning “Level 1” home, and had done reasonably well in a recent Resident Quality Inspection.  Counsel for the Ontario Association of Residents’ Councils and the Ministry of Health challenged her description of the Home, noting that many of the compliance orders were reissued multiple times.

Finally, Natalie Moroney testified about her role as a Ministry of Health Inspector. Ms. Moroney was assigned to lead the inspection at Meadow Park following Ms. Wettlaufer’s confession.  She described the steps taken in the inspection which included interviewing over 51 employees, physicians, managers, and family members of the victim.

As a result of the inspection, Ms. Moroney raised concerns regarding the medication management system which was widespread throughout the Home.  She issued a compliance order during the inspection and, following the inspection, she issued eight written notifications of non-compliance, seven of which were accompanied by Voluntary Plans of Correction. One of the findings included a failure to report three different allegations of suspected abuse of residents to the Director, including one involving the victim, Arpad Horvath, in the months prior to his death.  In July 2017, a follow up inspection was held.  Two compliance orders were reissued at that time.

Like Ms Kukoly, Ms. Moroney testified that she was proud to be a nurse. She explained, “I love being a nurse, I’ve always loved being a nurse. Nurses are caring and compassionate and empathetic. They’re the advocate, they’re truthful, and that’s what nursing is all about.  It’s about giving care and giving dignity.”

Ms. Moroney will be cross-examined on August 3, 2018.

August 1, 2018

Rhonda Kukoly, a Ministry of Health and Long-Term Care inspector and a former Director of Care (DOC), testified on August 1. She was assigned to inspect Caressant Care Woodstock (CCW) following Elizabeth Wettlaufer’s confessions and was instrumental in issuing the orders that ultimately led to the cease admission and mandatory management orders.

She began by describing her general practice in conducting inspections, both those in response to complaints and reports, and the annual Resident Quality Inspections (RQI).

Ms. Kukoly conducted the inspection at Meadow Park in September of 2014 when a card of narcotics went missing. She was advised that the Home suspected nurse Elizabeth Wettlaufer had stolen the narcotics as she had disclosed a drug and alcohol addiction prior to resigning. Ms. Kukoly testified that she usually will confirm with the Home that it would be filing a report with the College of Nurses of Ontario but in this case, because she did not document that she asked, she could only assume that she did not do so.

Ms. Kukoly then testified about the inspections at Caressant Care Woodstock following Ms. Wettlaufer’s confession.

Immediately after learning about the murders, former Director of Ministry Inspections Karen Simpson assigned Ms. Kukoly to lead the inspection at CCW which included inspecting the critical incidents related to the murders and other critical incidents and complaints filed about the Home that had not yet been investigated.

Ms. Kukoly testified that this was an inspection without precedent. She went to the Home first on October 5, 2016 and gathered Ms. Wettlaufer’s personnel file, but was not permitted back into the Home until the police investigation concluded and charges were laid on October 28, 2016.

At that time, she commenced interviewing staff, management, members from corporate head office, physicians and pharmacists, and family members of the victims. Those interviews were audiotaped for the first time ever. Ms. Kukoly ultimately issued 13 written notifications of non-compliance, five of which were accompanied with voluntary plans of correction. The inspection also revealed that between August and December 2016, there were 41 medication errors, which, in addition to being a high number, were not all reported to the pharmacy and the DOC.

In January 2017, Ms. Kukoly issued two immediate compliance orders which are orders issued while an inspection is ongoing. Six other orders were subsequently ordered. Following the issuance of those orders, the Director issued a cease admissions order based on her concern that the residents’ health and well-being was at risk until the Home was in compliance with the requirements of the Long-Term Care Homes Act.

In May 2017, Ms. Kukoly returned to the Home for a follow-up inspection and found evidence of ongoing non-compliance. Orders were reissued.

In August 2017, Ms. Kukoly continued to be concerned about issues of non-compliance. As a result on September 1, 2017, the Director issued a mandatory management order which permitted the Ministry to appoint a third-party to manage the Home. By October 2017, improvements were noted, and in December 2017, the cease admissions order was finally lifted.

Ms. Kukoly concluded her testimony with an emotional description of the effect that the inspections had on her. She described her pride in being a nurse, and her belief that the inspection program was a valuable tool in ensuring residents’ rights were protected. She stated that she couldn’t think of anything that would detect “someone so evil and devious” who wanted to intentionally harm residents and conceal their actions and that she hoped that the Inquiry could come up with an answer.

July 31, 2018

On July 31, former Ministry of Health and Long-Term Care inspections branch director Karen Simpson was cross-examined by the parties.

She was asked questions about funding as it relates to the nursing and personal care envelope.  Ms. Simpson confirmed that funding in that envelope is partially based on acuity levels, but is mostly driven by budgets, not the needs of residents.

She also confirmed that she does not know of any study that shows that the amount of funding is sufficient for nursing homes to properly care for increasingly ill residents. In contrast, in response to questions from ONA counsel, Ms. Simpson confirmed that there have been a number of independent studies over the past 14 years that have found that funding and staffing in long-term care is problematic.

Ms. Simpson was not able to provide much evidence on funding and suggested that other directors in the Branch would more be more appropriate to speak to funding issues. These directors are not, however, scheduled to testify during the hearing.

Ms. Simpson confirmed that there is a general lack of understanding of mandatory reporting requirements to the Ministry of Health and Long-Term Care. Caressant Care Woodstock in particular seemed to not understand its reporting requirements, although this was not found to be an issue until the ministry did a “deep dive” into the home’s systems and practices.

ONA counsel asked Ms. Simpson questions about the 24/7 RN minimum staffing requirement contained in the Long-Term Care Homes Act. She clearly stated at least three times that she believes that it is essential for an RN to be on duty at all times, due to the complexity and acuity of residents and the fact that an unexpected incident could occur at any time.

Ms. Simpson did not agree that it would be sufficient for a home to be solely staffed by RPNs. Ms. Simpson also agreed that the minimum staffing requirement was a floor and that it might not be sufficient to meet resident care needs, particularly at night. However, she stated that it was up to the licensee to determine exactly how it staffed the home, so long as it met the minimum requirements set out in the Act.

Ms. Simpson also confirmed that ONA is a valued partner in long-term care and is active in consulting and meeting with the ministry. She testified that she personally meets with ONA regularly, and in addition, she noted that ONA and its members will often call to report specific concerns. For example, she noted that has received calls from ONA about infection prevention and control, and 24/7 staffing issues.

July 30, 2018

The Inquiry began the week with a focus on the Ministry of Health and Long-Term Care. Commission counsel Megan Stephens provided a summary of the complex legislative schemes that govern Long-Term Care Homes and Home Care in Ontario.

The first witness was Karen Simpson, the former Director of Compliance at the Ministry of Health and Long-Term Care. Ms. Simpson reviewed the legislation, including mandatory reporting and medication management requirements, and provided a brief explanation of funding for long-term care.

Ms. Simpson discussed the inspection process under the Long-Term Care Homes Act, which includes inspections done in response to complaints and reports received and annual inspections called ‘RQIs.’

Ms. Simpson emphasized that the inspection system depends on complaints from residents and their families, staff or the broader public, and mandatory reports filed by the licensee, so that the inspectors can then look into the concerns raised. She described the various enforcement mechanisms that may be put in place following a finding of non-compliance with the Act, which range from written notices to a revocation of a license.

Ms. Simpson then turned to the inspections that were conducted following Elizabeth Wettlaufer’s confession in October 2016. Those inspections led to an order to cease admissions at Caressant Care Woodstock.

After several months, it became clear that the home was still not compliant with its obligations under the Act, and Ms. Simpson issued a mandatory management order, placing the home under the management of a third party contracted for that purpose.

In December 2017, the order to cease admissions was lifted, but the mandatory management order remains in place. There were also findings of non-compliance against Meadow Park and Telfer Place long-term care homes, but it was unnecessary in those cases to cease admissions and issue mandatory management orders.

Further details about the Wettlaufer inspections will be provided when the inspectors testify later this week.

July 27, 2018

On July 27, 2018, Karen Yee, the College of Nurses' of Ontario (CNO) intake investigator who assessed the Caressant Care Woodstock report filed in May 2014, testified.

Ms. Yee, who is both a nurse and a lawyer, and had worked at the CNO for approximately eight years at the time she was assigned to Ms. Wettlaufer’s termination report, reviewed the training, duties and responsibilities of an intake investigator.

Ms. Yee testified that once she was assigned to the Wettlaufer file, she reviewed the 1995 fitness to practice file and the Caressant Care Woodstock report. Ms. Yee spoke to Caressant Care Woodstock’s Helen Crombez on the phone.  Ms. Crombez did not indicate that she thought that Ms. Wettlaufer was unfit to be a nurse or incapacitated and she confirmed that Ms. Wettlaufer did take responsibility for her actions.

Following her review of the file and her discussion with Ms. Crombez, Ms. Yee wrote a memo recommending that the report be “banked with notice.” She considered the medication errors contained in the report to be relatively minor and representing only a low risk to the public. Her conclusion was that Ms. Wettlaufer’s practice was at the lower end of acceptable. Ms. Yee’s recommendation was reviewed at a meeting with other intake investigators, who unanimously agreed with her opinion. She then sent her recommendation to Ms. Coghlan, who approved the recommended action.

Ms. Yee was cross-examined about the investigation process. She admitted that she may not have reviewed every single document in the historical fitness to practice file, but that she certainly would have reviewed key portions of it. She was also asked about why she thought that Ms. Wettlaufer demonstrated insight and accountability into her actions, when she clearly continued to make medication errors. Ms. Yee testified that she understood that Ms. Wettlaufer took responsibility from the comments on the report form and her conversation with Helen Crombez.

July 25/26, 2018

On July 25, direct examination of Anne Coghlan continued. She was asked to review the report on Ms. Wettlaufer from Caressant Care Woodstock and provide her opinion on each of the incidents listed.

Ms. Coghlan noted that because one of the reported incidents involved a missing narcotic, the intake investigator would be looking to see whether there was a potential health issue, particularly given the 1995 incapacity finding, but that in this case, there did not appear to be a current incapacity issue.

Ms. Coghlan was then asked to voice her thoughts about a number of the incidents that had not been included on the report, including the bowel disimpaction of a resident who was screaming in pain, using unsterile scissors to puncture a hematoma, and the complaints of coworkers that Ms. Wettlaufer would refuse to return from break to provide residents with pain medication.

Ms. Coghlan characterized all of these incidents as abuse and/or neglect and would be things that should have been reported to the CNO. If they had been reported, a very different pattern would have emerged.

Cross-examination of Ms. Coghlan then continued for the next day and a half. In cross-examination, Ms. Coghlan described the process for triaging complaints and reports once received by the CNO in order for the most urgent to be dealt with first.

She confirmed that the grievance process has no impact on the CNO and she stated that it would not be helpful for the CNO to be provided with a complete copy of the personnel file for the nurse at the time a report is filed.

Ms. Coghlan explained that this was because the personnel file often contains a lot of extraneous human resources material that is of no consequence to the assessment to be conducted by the intake investigator, which is to determine the level of risk posed by the nurse’s actions. Instead, she repeatedly testified that it was more important for a facility operator or employer to provide comprehensive reports detailing their concerns with the nurse’s practice that led to the filing of the report.

Ms. Coghlan confirmed that Meadow Park, the nursing home that Ms. Wettlaufer worked in following Caressant Care Woodstock, should have filed a report with the CNO when Ms. Wettlaufer advised them that she had a health issue prior to her resignation, and that they should have filed a report when they had reasonable grounds to suspect that she had stolen hydromorphone on her last shift at the home.

Ms. Coghlan was aggressively challenged by the lawyer for Caressant Care Woodstock, David Golden, on the CNO’s actions following receipt of the report submitted by the home. Despite the lengthy questioning, Ms. Coghlan steadfastly maintained that the information provided by Caressant Care Woodstock was not such as to justify a formal investigation.

Under cross-examination by the Ontario Nurses’ Association’s (ONA) counsel, Ms. Coghlan confirmed that since Ms. Wettlaufer’s confession, the CNO has new powers to suspend a nurse’s license on an interim basis. She also confirmed that many nurses who are found to be incapacitated are still able to work, with the imposition of terms and conditions on the license for a period of time.

Most importantly, Ms. Coghlan testified that it was important to not treat all nurses who have mental health disabilities as if they are potential serial killers. The fact that Ms. Wettlaufer was a “recovered alcoholic” was not a red flag for a nurse who was intentionally harming residents.

Ms. Coghlan testified that even in hindsight, there was nothing remarkable in Ms. Wettlaufer’s file to suggest that she had committed such terrible offenses. The file did not contain any clues that would have led the College to be able to discover her crimes prior to her confession.

July 24, 2018

On July 24, the next phase of the Inquiry related to the College of Nurses of Ontario (CNO) commenced.

Commission Counsel Rebecca Jones began with an overview of the relevant legislation, noting that much of what the CNO does is prescribed by the Regulated Health Professions Act (RHPA), the Health Professions Procedural Code (“the Code”) and the Nursing Act and its regulations.

Ms. Jones then briefly reviewed the involvement of the College with Elizabeth Wettlaufer, who was a member from June 1995 until July 2017, when the College revoked her membership.

During that period, the CNO was involved with Ms. Wettlaufer on three occasions: first, following her termination in 1995 from Geraldton District Hospital, which resulted in a finding of incapacity and conditions being placed on her registration for a year; second, following her termination from Caressant Care Woodstock in 2014, which resulted in the College “banking with notice” the information; and third, following her confession.

Anne Coghlan, the Executive Director and the Chief Executive Officer of the CNO, then testified about the role of the CNO as the College for more than 175,000 RNs and RPNs in the province.

She described four main roles of the CNO:  setting the requirements to become a nurse, informing nurses of their accountabilities through the creation of professional standards, responding to concerns about nursing conduct, competence and health, particularly by responding to complaints or reports filed with the CNO, and a quality assurance program which includes random audits.

Ms. Coghlan provided details about how the CNO responds to complaints and reports.  With respect to mandatory reports made by a facility operator or employer, the CNO appoints an intake investigator who reviews the report, contacts the reporter to gather more information, and then makes a recommendation on how to address the report, considering the level of risk.

For reports involving a significant risk to the public, the intake investigator will recommend that the report proceed to a formal investigation. For reports involving less risk, the report might be “banked” with or without notice to the nurse, or the nurse might be asked to review materials and attend a meeting with a Director or the Executive Director.

As the Executive Director, Ms. Coghlan reviews all recommendations made by an intake investigator, and will also review some of the key documents, including the report. Ultimately, she approves all decisions made regarding reports.

Ms. Coghlan testified about the CNO’s involvement with Wettlaufer in 1995, following her termination from Geraldton District Hospital. At that time, Wettlaufer’s file was referred to the fitness to practice committee because her termination was related to a health issue. After being sent for three independent medical examinations, including with an addictionologist and a psychiatrist, the CNO entered into an agreement with Wettlaufer placing terms, limitations and conditions on her registration for a one-year period.

Ms. Coghlan then testified to the report received by the CNO from Caressant Care Woodstock in May 2014. She testified that the intake investigator, Karen Yee, had reviewed the report, contacted Caressant Care Woodstock’s Helen Crombez and determined that the concerns listed in the report represented a low level of risk.

Ms. Coghlan confirmed that many of the medication errors referenced in the report were common, particularly in a long-term care setting where the nurses are extremely busy and there is minimal staffing in place. She ultimately accepted the intake investigator’s recommendation that the report be “banked with notice.”

July 23, 2018

On July 23, 2018, the Inquiry heard testimony from the Ontario’s Chief Pathologist, Dr. Michael Pollanen. Dr. Pollanen testified about the role of forensic pathology in the death investigation system.

He explained that the current system in Ontario is that of a coroner’s system, wherein the role of pathologists is primarily to conduct post-mortem examinations (autopsies) upon the request of the investigating coroner.

The forensic pathologist provides a medical and scientific answer to the question of cause of death, where possible, but the coroner has the final responsibility for determining the cause of death. The coroner will consider not only the autopsy results, but any other relevant information gathered during the death investigation, including, for example, confessions.

Dr. Pollanen testified that the death investigation system was strengthened following the Goudge Inquiry, which led to amendments to the Coroner’s Act. Previously, the Coroner’s Act did not even reference pathology as a tool in death investigations. Now, the Act sets out the responsibility of the chief pathologist and provides that only those pathologists on a register may conduct autopsies for the purpose of death investigations.

Dr. Pollanen testified about insulin and the difficulties in detecting that a death was due to the intentional administration of insulin.

If a patient experiences a hypoglycemic episode, goes into a coma and then dies, it might be possible to detect it in an autopsy through examination by a neuropathologist, who could find signs of hypoglycemic encephalopathy.

These signs are often misinterpreted in imaging as a stroke. In the absence of a coma, Dr. Pollanen testified that a death due to hypoglycemia is difficult to detect: the symptoms are non-specific to the condition, and it is difficult to determine whether the insulin is exogenous or internally produced.

Additionally, there are no labs in Canada that are qualified to test for insulin; insulin itself degrades quickly in the body after death.

Dr. Pollanen then testified about the retrospective investigation that he performed following Elizabeth Wettlaufer’s confession.

He performed autopsies on the two victims who had not been cremated, but was unable to conclusively link their deaths to hypoglycemia. As a result, he listed the cause of death as undetermined. He also reviewed the medical records of the other victims; again, Dr. Pollanen was unable to conclusively determine that the cause of death was due to hypoglycemia.

He testified that although he was not able to definitively opine on the cause of death, the coroner was able to do so, because he was able to confirm that the information in the medical records was consistent with Ms. Wettlaufer’s confession.

Dr. Pollanen referred to Maureen Pickering’s death as a missed opportunity, because she had experienced a coma followed by death. He testified that he believes that if an autopsy been performed at the time, they might have been able to at least determine that Ms. Pickering had died as a result of the administration of exogenous insulin.

July 19, 2018

On July 19, the Inquiry heard testimony from Dr. Elizabeth Urbantke, a local investigating coroner.

Dr. Urbantke testified about her process in conducting death investigations in long-term care homes and admitted that it had been close to a year, at least, since she had done an investigation in a long-term care facility.

At times, she said, when she did threshold death investigations (every tenth death), she would find missed coroner's cases, but she stopped short of stating that she found those to be helpful, as Dr. Mann had testified earlier in the week. Unlike Dr. George, Dr. Urbantke testified that she kept notes even when she ultimately determined that it was not necessary to conduct a death investigation.

Dr. Urbantke was asked whether she considered the possibility of a care provider harming a resident. She said that she kept an open mind but before this case, likely thought of intentional harm as physical harm or neglect.

She was then asked about the threshold death investigation she performed on Wayne Hedges.  Mr. Hedges passed away following a stroke several months after Wettlaufer attempted to murder him. Dr. Urbantke had no independent recollection of her investigation but did have notes and reviewed those notes in her testimony.

Dr. Urbantke then testified about her involvement with Caressant Care Woodstock resident Maureen Pickering, who was admitted to the emergency department with very low blood sugar after being injected with insulin by Elizabeth Wettlaufer.

Dr. Urbantke had no independent recollection of the incident but did confirm that she likely was concerned that there had been a medication error that had led to the low blood sugar. She did not believe that she considered whether a care provider may have intentionally harmed Ms. Pickering.

Given the passage of time, she could not recall whether she had a conversation with Dr. George at the time, but admitted that if she had, she would not have maintained notes, because it was not her investigation.

Testimony will continue on Monday July 23, 2019 when Dr. Pollanen, the Chief Forensic Pathologist, takes the stand.

July 18, 2018

Regional Supervising Coroner Dr. Rick Mann was cross-examined, reiterating his belief that he found value in the “threshold death investigation” process (investigating every tenth long-term care death).

Dr. Mann stated that such investigations allowed the coroner to see patterns that might not otherwise be picked up and allowed them to find cases that should have been investigated. He testified that he provided his opinion at the time that the threshold investigations were stopped. Dr. Mann also indicated that he was not aware that Maureen Pickering's death had not been investigated because it was not part of the process to be notified when an investigation was not initiated.

Local coroner Dr. William George, who investigated the death of James Silcox and who was also contacted regarding the death of Maureen Pickering, also testified.

Dr. George became a coroner in 2004; he estimated that he is called seven to eight times monthly to conduct death investigations. He provided evidence regarding his typical process when asked to do a death investigation, and indicated that his process for investigations in long-term care homes was similar, except that he also reviews the death registry. He stated that he always attempted to contact the family.

Dr. George testified that in circumstances where he determined that a death investigation was not required, he would dispose of any notes he had taken within a few weeks. He also indicated that he did not fill in the Case Selection Forms that indicated his assessment that a death investigation was not required, despite his understanding that completion of the form was mandatory.

When asked how many death investigations in long-term care facilities he has recently conducted, he admitted he had not done any in a few years. Dr. George testified that he struggled with the use of the phrase "sudden and unexpected" deaths when used in relation to long-term care, suggesting that a better question would be whether the death was foreseeable. He testified that it was highly unlikely that any death in long-term care would be unexpected.

With respect to his investigation into James Silcox's death, he testified that he would have examined the body, reviewed the death registry, spoken to the nursing staff on duty and he would have attempted to speak with the family.

He denied the suggestion that he was dismissive towards Mr. Silcox's family, stating that he had respect for the dead and their family and that he would often meet with family members to answer questions in his office. Dr. George testified that in reviewing the chart again, he did not feel he had missed anything.

Dr. George was then asked about his involvement following the death of Maureen Pickering. As had been previously reported, Karen Routledge, RN, had contacted the coroner when Ms. Pickering passed away, following the suggestion of the Emergency Room physician (and local coroner) Dr. Elizabeth Urbantke.

Dr. George testified that he spoke to Ms. Routledge, considered the information provided, including the fact that Dr. Urbantke was concerned about Ms. Pickering's unexplained low blood sugar level, and likely also reviewed any available medical records.

He concluded that there was no need to do a death investigation, as Ms. Pickering was palliative and the CT imaging showed that she had experienced a stroke. He testified that the low blood sugar could have been the result of a medical error, but that he wouldn't investigate unless it was a precipitating factor in the death, which he did not believe it was.

Dr. George was asked whether, considering all that is now known, he should have investigated Ms. Pickering's death. He replied that he would not, as her death was foreseeable and expected.

When reminded by counsel that Ms. Pickering was only palliative after her return from the hospital – which was as a result of an insulin overdose – he reiterated that she was palliative.

Dr. George also testified that he had not considered that a health-care provider would harm a patient, but resisted the suggestion that his mind was closed to the possibility.

July 17, 2018

Ontario chief coroner Dr. Dirk Huyer was cross-examined extensively by lawyers representing the families, the facilities and the Ontario Association of Resident Councils (OARC) on Tuesday.

Alex Van Kralingen, counsel for one group of the families, asked Dr. Huyer about the paucity of formal education and training of coroners. He also asked about the importance of coroners in speaking to the families of the decedents. Dr. Huyer confirmed that it was his expectation that the coroner speak to the family when conducting a death investigation.

Interestingly, Dr. Huyer testified that local coroners do not have the authority to access medical records prior to an investigation: they can only review those records once the decision to investigate has been made. When a coroner is deciding whether or not to do a death investigation, they have access only to information provided by the reporter of the death and anyone else they decide to speak with. Dr. Huyer confirmed that having access to the medical records would be a benefit to the death investigation system.

He also testified that it was his expectation that local coroners keep notes when they decide not to do a death investigation, saying that if notes were not kept, it could become a performance issue. He indicated that the new IT system would require specific documentation so that the case could not be closed without documentation indicating why the coroner exercised discretion to not perform a death investigation.

Under questioning from Suzan Fraser, counsel for the Ontario Association of Residents' Councils, Dr. Huyer agreed that the fact that Wettlaufer's murders went unnoticed by the death investigation system was a failure of that system.

The next witness was Dr. Richard Mann, the Regional Supervising Coroner for the West Region London Office. He testified about his role as a supervisor of the local investigating coroners, including mentoring new coroners, conducting performance evaluations and reviewing "case selection data forms" sent by local coroners, advising that a death will not be investigated, amongst other responsibilities.

Dr. Mann testified that he felt uncomfortable when coroners ceased doing death investigations into the threshold deaths (every tenth death) in a long-term care home, as that process allowed them to be a presence within the home, view the death registries and generally review the situation in the home.

He also testified that he felt that they could have, as an organization, done better, although he wasn't able to point to anything in particular that could have been done differently.

Dr. Mann concluded his evidence in direct and will be cross-examined on July 18, 2018.

July 16, 2018

Following a two-week break, the Long Term Care Homes Inquiry resumed on July 16 in St. Thomas. The focus for the next five days of testimony will be on the Office of the Chief Coroner (OCC)/Ontario Forensic Pathology Service (OFPS) and in particular, the intersections between the OCC/OFPS with the Wettlaufer offences.

The first witness was Dr. Dirk Huyer, Ontario’s Chief Coroner. Dr. Huyer provided testimony about the role of coroners, death investigations generally and in long-term care in particular, and his role in the retrospective investigations that occurred following Ms. Wettlaufer’s confession.

Dr. Huyer testified about the historical evolution of the coroner’s system in Ontario. Currently, there are 350 local coroners distributed throughout 10 regions throughout the province. Most of those coroners maintain their own practice and perform death investigations on a part-time basis. Coroners receive five days of training once appointed to their role, and may attend yearly educational programs should they wish to do so.

In terms of long-term care, Dr. Huyer testified that all deaths occurring in long-term care homes must be reported to the coroner. The report is done by way of filling out an Institutional Patient Death Record form (“IPDR”), which currently contains eight questions, including whether the death was accidental or sudden and unexpected. If any of the questions are answered positively, the long-term care home is required to also call the coroner, in addition to faxing the IPDR to them. The coroner then has the discretion to investigate the death if he/she feels that it is appropriate to do so.

Dr. Huyer testified that until 1995, all long-term care deaths were mandatorily investigated by a coroner. Between 1995 and 2013, every tenth long-term care death, which was referred to as a threshold death, was investigated, in addition to any other death that the coroner believed should be investigated pursuant to the information received on the IPDR.

Since 2013, the requirement to mandatorily investigate every tenth death has been removed. Currently, coroners only investigate deaths in long-term care homes if they feel it is appropriate to do so, given the information provided on the IPDR.

If a coroner does a death investigation, their findings are set out on a “form 3” document. If the coroner exercises his/her discretion to not investigate a death, there is no similar requirement for documentation. Dr. Huyer testified that while he would expect coroners to keep notes detailing their rationale for not conducting an investigation, there was no legal requirement for them to do so.

When a coroner does a death investigation, he/she has the option to ask for a post-mortem examination. Dr. Huyer testified that autopsies are very rare in long-term care.

Finally, Dr. Huyer gave evidence of a number of steps taken since Ms. Wettlaufer’s confession. The IPDR form is in the process of being revised. He is trying to modernize the appointment of coroners’ process so that their appointment is time limited, and reappointment is tied to a requirement for continuing education. He also testified that the IT system is being modernized so that information can be gathered for the purpose of analytics, and with the hope that patterns can be identified.

June 28, 2018

The cross-examination of St. Elizabeth Health Care Health Services Supervisor/Clinical Practice Coach, Tamara Condy, continued on June 28, 2018.

Ms. Condy was asked if she had ever received any training in human resources, including interviewing. She replied that while she had been mentored, she had not been provided with formal training. She was also asked about the starting salary at St. Elizabeth, which was $27.20 per hour. Ms. Condy confirmed that the salary, which was set by St. Elizabeth, was low, but testified that nurses with experience could provide a letter demonstrating their hours of work elsewhere and be placed higher on the grid. Ms. Wettlaufer did not provide such a letter.

When asked why she didn’t call the references directly, Ms. Condy indicated that it wasn’t the human resources policy of St. Elizabeth and she didn’t think to call them or to question the policy.

Ms. Condy also testified that she had assigned another nurse, in addition to a preceptor, to work with Ms. Wettlaufer on issues regarding PICC lines and sterile fields. That nurse advised her that she had concerns with Ms. Wettlaufer’s practice in general, saying she appeared nervous, unorganized, a bit argumentative and resistant to coaching. Ms. Condy testified that she had not yet reached a stage where she was considering whether Ms. Wettlaufer’s employment with Saint Elizabeth should continue and did not consider filing a report to the College of Nurses of Ontario.

Patricia Malone, an RN employed as the Corporate Integrity Officer for Saint Elizabeth Health Care, testified last. Ms. Malone testified about the reference system, particularly that it was anonymous and online and that the employer would not make specific phone calls to the references unless there were red flags and consent from the applicant was obtained.

This practice has changed somewhat, she said – references are no longer anonymous so that specific comments can be attributed to the individual providing the reference. She also testified about incident reporting systems, both those internal to Saint Elizabeth and to the Local Health Integration Network. While testifying, Ms. Malone asked, “if you can’t trust a reference, where do you go to ensure safety of clients?”

In cross-examination, counsel for Caressant Care Woodstock questioned whether the Ministry of Health investigated Saint Elizabeth, or requested documentation from them. He noted that the Ministry came into Corporate Care Woodstock and did a five-month investigation, and asked whether anything similar was done either by the Ministry or the Local Health Integration Network/Community Care Access Centre. She confirmed that no such investigation was done.

Following the viva voce evidence, there were two affidavits admitted into evidence. First, an affidavit from Caressant Care Woodstock’s Helen Crombez was entered in which Ms. Crombez indicated that she did not recall saying in the step 2 meeting with ONA Labour Relations Officer Jill Allingham that Ms. Wettlaufer was an incompetent nurse. Ms. Allingham’s evidence and her notes indicated that Ms. Crombez did question Ms. Wettlaufer’s competency in the meeting.

Second, Mr. Van Kralingen entered an affidavit from Laura Jackson, a friend of Maurice Granat, one of Ms. Wettlaufer’s victims. In the affidavit, Ms. Jackson describes an interaction with Ms. Wettlaufer with Mr. Granat in the hours immediately prior to his death.

The Facilities portion of the Inquiry is now completed. The Inquiry will resume on July 16, with a focus on the Coroner’s office.

June 27, 2018

On June 27, 2018, the Commission heard from Carol Hepting, the Vice-President of Operations at Caressant Care.

She testified that she was involved in the decision to terminate Elizabeth Wettlaufer’s employment from Caressant Care Woodstock, and that in doing so, she had noted that Ms. Wettlaufer’s actions appeared to be dangerous.

She commented on the fact that nurses had in the past worked "many, many" double and triple shifts at the home. Ms. Hepting also testified to a letter that she wrote to the College of Nurses of Ontario in October 2014, when she learned from the police of Ms. Wettlaufer’s offenses. She wrote to the College that Caressant Care was wished to "restate" its position that Ms. Wettlaufer was unfit to safely practice nursing and asked that her letter be given urgent attention.

Ms. Hepting then faced a vigorous cross-examination from several parties, including the College of Nurses of Ontario, who noted that although she stated the matter was urgent, the letter was mailed and not faxed to their attention.

Ms. Hepting admitted that she was not aware of the content of the initial report filed to the College and that she had been unaware that Helen Crombez had not been of the opinion at the time of the termination that Ms. Wettlaufer was incapacitated, incompetent or otherwise unfit to work as a nurse.

Ms. Hepting will be recalled to testify during the Ministry of Health and Long-Term Care phase of the Inquiry, so she can give evidence on the Ministry inspections that occurred following Ms. Wettlaufer’s confession. These inspections led to the Ministry ordering Caressant Care Woodstock to no longer admit new residents between January and December 2017.

The second witness was Tamara Condy, a Health Services Supervisor and Clinical Practice Coach with St. Elizabeth Health Care. Ms. Condy interviewed and hired Ms. Wettlaufer at St. Elizabeth in June 2016, where she worked until her resignation in August 2016. It was during her time at St. Elizabeth that Ms. Wettlaufer attempted to murder Beverly Bertram.

Ms. Condy testified that Ms. Wettlaufer had applied for a position in 2014 with St Elizabeth but she did not interview her, both because there was a more qualified candidate and because another nurse at St Elizabeth had worked with Ms. Wettlaufer at Caressant Care Woodstock; she advised Ms. Condy that there were strange circumstances surrounding Ms. Wettlaufer's employment and that she didn't fit in well.

In 2016, Ms. Wettlaufer applied for a second time. In terms of the hiring process, St. Elizabeth used an online reference system. Ms. Wettlaufer's references included Sandra Fluttert, Robyn Laycock and the RAI Coordinator at a long-term care home where she worked as an agency nurse.

Ms. Condy confirmed that she was not provided with the written reference letter from Caressant Care Woodstock that had arisen from the settlement of the grievance. She also was not provided with any information arising out of Ms. Wettlaufer’s employment at Geraldton Hospital.

In the interview, Ms. Condy did ask Ms. Wettlaufer about the circumstances surrounding her departure from Caressant Care. She testified that she was told that she had made a med error in which she put the wrong insulin cartridge into another patient's pen and that the patient had received the wrong insulin for a period of time. Ms. Condy thought that her honesty was brave and decided to hire her.

Ms. Condy testified that Ms. Wettlaufer struggled with maintaining a sterile field and dressing PICC lines, but that she eventually was certified to perform such dressings. She had just started to be assigned her own patients when she abruptly resigned in late August 2016, leaving behind some of her own personal equipment (stethoscope, blood pressure cuff) in addition to St. Elizabeth property.

In cross-examination, ONA confirmed that the nurses at St. Elizabeth were not unionized.

Tuesday, June 26, 2018

Three witnesses from Telfer Place – the Paris, Ont., long-term care home where Elizabeth Wettlaufer was sent as an agency nurse – testified on June 26.

The Commission heard from:  executive director Dian Shannon, director of care Sherri Toleff and the director of care as of April 2016, Michelle Cornelissen.

Dian Shannon testified that she is not a registered health professional and talked about staffing levels, orientation and agency usage at Telfer Place. With respect to staffing levels, she testified that the home had difficulty recruiting and retaining registered staff because of the high resident-to-staff ratio. Nurses commented on these high levels during employment interviews and orientation; at times, nursing candidates would not return.

Ms. Shannon also testified about her interactions with Ms. Wettlaufer. She said that that on December 28, 2015, Ms. Wettlaufer had been scheduled to work as an agency nurse at Telfer Place, but called in sick at the last minute. The home was unable to find another RN to work in her place, so they had to call in an agency RPN. Ms. Shannon went to the home and worked with that RPN, helping to administer medications.  She testified that she even administered insulin to a resident, an event which she subsequently reported to her superiors and to the Ministry of Health.

Ms. Shannon also testified during an enteric outbreak, due to the lack of staff she worked one night shift with Ms. Wettlaufer. She recounted that she and Ms. Wettlaufer were checking on all the residents, many of whom were experiencing diarrhea and vomiting. When they reached resident Sandra Towler, they cleaned her, but Ms. Wettlaufer said before they were finished, that their efforts were “good enough.” Ms. Shannon disagreed and told Ms. Wettlaufer that they needed to fully clean her, change the sheets and her clothing. After that, she went and checked on all the residents previously seen by Ms. Wettlaufer to ensure that they had been sufficiently cleaned. Ms. Shannon also testified that she was annoyed with Ms. Wettlaufer because when she entered Sandra Towler’s room, she was loud, and could have woken up the other three residents in the room.

Ms. Shannon testified that her opinion of Ms. Wettlaufer was that she was lazy. Her impression was furthered when a Personal Support Worker complained that her back was starting to hurt because Ms. Wettlaufer refused to help her reposition and toilet residents during night shifts. Shortly thereafter, they also received the complaint from Dr. McDonald and advised their nursing agency, Lifeguard, that they no longer wished to have Ms. Wettlaufer at Telfer Place.

Sherri Toleff testified about the orientation process for agency nurses, confirming that they received between four to eight hours of orientation, in contrast to the approximately six shifts of orientation, including classroom training, received by regular staff. She testified that when concerns were raised regarding agency staff, it was her usual practice to speak to the agency nurse and the agency itself. As such, she believed that she had spoken to Heidi Wilmot-Smith, owner of the nursing agency, about several incidents involving Ms. Wettlaufer.

Michelle Cornelissen testified that when she became the director of care at Telfer Place, she was quickly advised by a Personal Support Worker and Dr. McDonald of concerns relating to Ms. Wettlaufer. In response, she decided that Ms. Wettlaufer would no longer be welcome to work at Telfer Place. She advised Heidi Wilmot-Smith of their decision, both verbally over the phone and via email. After that date, Ms. Wettlaufer never returned to the home.

Monday, June 25, 2018

The Commission heard from four witnesses today.

Robyn Laycock was the first witness of the day; she testified about her experience working as an RPN at Caressant Care Woodstock alongside Ms. Wettlaufer. Ms. Laycock testified about a number of incidents involving Ms. Wettlaufer, including:

  • She believed that she smelled alcohol on Ms. Wettlaufer’s breath once, and advised the other nurse on duty, who may or may not have been Karen Routledge. That nurse then checked, returning and advising her that she did not smell anything.
  • Shortly after Ms. Laycock started working at Caressant Care as a new graduate, Ms. Wettlaufer advised her that the resident in the palliative care room required Dilaudid. Laycock had just assessed the resident and determined that Dilaudid was not required. Despite explaining her assessment, Ms. Wettlaufer insisted that the resident be given the painkiller. Ms. Laycock was clear that this was not a medication error, in that the narcotic had been ordered and was administered within the parameters of the order, but in her opinion, it was unnecessary, given the resident’s condition.
  • Laycock also indicated that she was “livid” upon hearing Ms. Wettlaufer’s comments to palliative residents. She testified that she overheard Ms. Wettlaufer telling patients that, “if you want to let go, it’s ok” and other comments of a similar nature. She described these comments as immoral. She told Ms. Wettlaufer that she felt her comments were inappropriate. It was after hearing these comments that she began to call Ms. Wettlaufer the “Angel of Death.”
  • Laycock also recalled in either in late-2011 or early-2012, she reviewed the death registries as she had noticed that in one month, there had been an above-average number of resident deaths. She was unable to pin down the exact time period that she looked at the registry. She considered cross-checking the deaths with Ms. Wettlaufer’s schedule to see whether she had been on shift when the residents passed away, but did not complete this review.

Ms. Laycock testified that she had no idea that Ms. Wettlaufer was intentionally harming residents. She had heard that Ms. Wettlaufer would not always assess residents for PRN medications if she was on break, but because she didn’t know the particular residents and circumstances (i.e., when the resident had last had the medication) she had no reason to report these actions as abuse or neglect.

The second witness was Jonathan Lu, who is the Chief Quality and Clinical Services Officer at Silver Fox Pharmacy. Silver Fox Pharmacy became the pharmacy used by Meadow Park in August 2016 shortly before Ms. Wettlaufer confessed to her crimes. He testified to policies and procedures and audit standards that were put in place when Silver Fox transitioned to being the Home’s pharmacy.

He also testified to incident reporting, including reporting of medication errors. In his affidavit, Mr. Lu noted that the preferred practice for administration of insulin is an independent double check, but that it is not very practical given how busy nurses are in the long-term care sector. He noted that in many small homes, there is only one nurse on night shift so “who is supposed to do the double check?”

He was cross-examined by the Ministry of Health and Long-Term Care about findings made after the Ministry conducted interviews with staff at Meadow Park in October and November 2016 – after  Ms. Wettlaufer’s confession. Some of the findings related to pharmacy policies while others were more directly related to Jarlette policies.

The third witness was Dianne Beauregard, an RN working at the 45-bed Telfer Place home. She indicated that at the time that Ms. Wettlaufer was sent to work by an agency at Telfer Place, the home was staffed solely by RNs and PSWs: one RN per shift. As of 2017, the day and evening shifts are also staffed with an RPN.

Ms. Beauregard testified that she had no concerns about Ms. Wettlaufer’s practice. Ms. Wettlaufer told Ms. Beauregard that she one year sober, but did not report the comment as she had no reason to think that Ms. Wettlaufer’s care was anything less than competent.

On the night shift of September 6-7, 2015, Ms. Beauregard found a resident, Sandra Towler, non-responsive. Although Ms. Towler had never been hypoglycemic, Ms. Beauregard checked her blood sugar levels and learned they were very low. She called the paramedics, who arrived and administered IV dextrose. Ms. Towler was then roused, but her blood sugar remained low and when Ms. Beauregard returned for her next shift, she sent Ms. Towler to the hospital.  Ms. Wettlaufer later confessed to the attempted murder of Ms. Towler, confessing that she administered insulin during the evening shift of September 6, 2015. Ms. Beauregard testified that she never suspected that any staff had deliberately harmed Ms. Towler.

The third witness was Tracy Raney, an RN working at Telfer Place. Ms. Raney testified to the challenging staffing levels that were in place up until 2017, when the home added an RPN to the day and a portion of the evening shift. Prior to that change, there was only one RN on each shift. She noted that when an agency nurse was required, they would be given at most one shift of orientation and following that, they would be left alone and in charge. Ms. Raney also testified that she found agency usage problematic, that agency nurses were generally not as in-depth in their charting and assessments and that she was glad that the home was no longer using agency nurses.

Ms. Raney further testified that she filed a number of complaints regarding Ms. Wettlaufer with the Director of Care and the Assistant Director of Care. Initially she spoke to the DOC, but then started to send her concerns in writing via email. In January 2016, she reported that Ms. Wettlaufer was leaving the medication room and chart room doors open while she went down the hallway. She also reported that Ms. Wettlaufer was trying to find out whether the home was using another agency, as Heidi Wilmot-Smith believed they were being underbid. She filed a final report against Ms. Wettlaufer for failing to report a bleed after nail care, and for not calling the doctor when a resident was experiencing apnea. When Ms. Raney arrived for her shift, she called the physician, who then changed the resident’s status to palliative.

She also testified to an incident in which Ms. Wettlaufer had been reported to the Director of Care by a Personal Support Worker. According to Ms. Raney, Ms. Wettlaufer was furious at being reported, was determined to find out who had made the report, and ‘wanted to make them pay.’

The final witness was Tanya Adams, the Clinical Consultant Pharmacist at Meadow Park. She worked for the pharmacy contracted by Meadow Park prior to Silver Fox. Ms. Adams was involved in an investigation into missing narcotics at Meadow Park in late-September 2014. The medication had been delivered to the home, given to the receiving nurse who then distributed the medications to each of the nursing stations.

It was at this stage that the narcotics went missing:  the nurses on the Kent nursing station did not sign as having received the bag with the narcotics. This is the missing narcotic that the Director of Care, Administrator and even the police suspected had been stolen by Ms. Wettlaufer. Without definitive proof, no arrests or reports were made.

Friday, June 22, 2018

The Commission heard testimony from four witnesses on June 22.

Robert Vanderheyden, who was the Administrator at Meadow Park at the time Ms. Wettlaufer worked at the home, testified that he had little knowledge of Ms. Wettlaufer, but was involved with the investigation into missing narcotics following her resignation.

Mr. Vanderheyden offered thoughtful testimony about the many challenges faced by the long-term care system, including the way in which long-term care is funded.

He testified that although dining was important to the residents, the food budget was just $7.80 at the time. Mr. Vanderheyden also testified that the residents had more complex care needs, and that funding and staffing levels had not kept up with the changing acuity in residents. He testified that staffing in the home needed to be “quite a bit higher.” In cross-examination, he did not indicate what he thought an appropriate staffing ratio to be, but rather that he wanted to be able to assign RNs to care for the more acute residents.

The Commission next heard from Dr. John McDonald, who had interacted with Ms. Wettlaufer when she was placed by an agency as a nurse at Telfer Place. Dr. McDonald testified that he was required to speak with Ms. Wettlaufer about a patient one evening and that he had found her behavior to be extremely odd.

Dr. McDonald testified that he felt so uneasy about the interaction that he advised the Director of Care, who then advised Heidi Wilmot-Smith of the agency which sent Ms. Wettlaufer (Lifeguard) that Ms. Wettlaufer was no longer welcome at the home.  He said that it was a unique experience in his 42 years of practice.

Dr. McDonald also commented that it was challenging to work with agency nurses, because they didn’t have the same knowledge of the residents and that it challenged the natural professional relationship between physician and nurse.

Dr. Richard Reddick, Medical Director of Caressant Care Woodstock for more than 40 years, testified. Dr. Reddick was at Caressant Care during the time period during which Ms. Wettlaufer was there. He testified about his role as the Medical Director, and said he did not have any concerns at the time about Ms. Wettlaufer’s competency, describing her as adequate.

Dr. Reddick testified that he had not been made aware of the multiple practice issues raised during her employment with Caressant Care. Dr. Reddick testified to the conversation he had with Karen Routledge at the time of Maureen Pickering’s death, and his thoughts that she had been hypoglycemic. Dr. Reddick said that he knew that she had suffered a stroke and wasn’t sure whether the hypoglycemia was a result of the stroke, or a cause of the stroke. When he filled out the cause of death, he listed it as CVA (cardiovascular accident), noting that cause of death is primarily used for statistical purposes.

The clinical consultant pharmacist for the pharmacy serving Caressant Care Woodstock was the final witness for June 22. Joanne Polkiewicz’s evidence largely focused on medication practices at the home.

Thursday, June 21

The Commission heard testimony focusing on labour relations and the grievance process.

Caressant Care corporate HR Vice-President Wanda Sanganesi was cross-examined by participating parties and ONA called Jill Allingham, Labour Relations Officer, to provide evidence regarding ONA’s knowledge of the incidents leading to Elizabeth Wettlaufer’s suspension and discipline and settlement discussions.

In cross-examination, Ms. Sanganesi acknowledged that Brenda Van Quaethem and Helen Crombez had not made her aware of the details of earlier disciplines of Ms. Wettlaufer, including counseling, verbal and written warnings. She testified that she was unaware that there had been a previous one-day suspension relating to attendance issues. Most surprising, Ms. Sanganesi was not advised that issues arose in November and December 2013 and that non-disciplinary letters of warning had been provided to Ms. Wettlaufer. This was several months after the first five-day suspension. She testified that it would have been helpful for her to have had this information.

In justifying her decision to settle the grievance, Ms. Sanganesi stated that she believed that there were “vulnerabilities” to their case and that she estimated that they had only a 50-50 chance of success at arbitration. This meant that there was a real risk that Ms. Wettlaufer would be reinstated, in her mind. This was despite a long history of approximately 43 incidents addressed through a combination of counseling, verbal and written warnings and suspensions. Ms. Sanganesi confirmed that she did not seek a legal opinion about the merits of their case.

ONA counsel Kate Hughes, questioned Ms. Sanganesi at some length about the advice she had provided to the administrator and director of nursing. Ms. Sanganesi agreed that when she was providing advice, she was doing so based on the information she had been given, which was that Ms. Wettlaufer was a nice person, a good employee, with sporadic problems with no pattern to them, and that she might have had a memory issue. She also agreed that her advice on disciplinary matters was provided not because she was afraid of the union’s response, but rather, was based on her understanding that the employee was someone who screwed up” sometimes but who showed the ability to improve. In coming to that conclusion, she relied on Ms. Wettlaufer’s response in disciplinary meetings, which was to take responsibility for her actions and to apologize.

Ms. Sanganesi also testified that she did not provide ONA with the personnel file until after the step 2 meeting for the five-day suspension, issued in January 2014. When she did provide the file, it did not contain more than 30 of the more than 40 issues raised about Ms. Wettlaufer’s practice over her seven years with Caressant Care Woodstock.

With respect to the step 2 meeting, Ms. Sanganesi confirmed that they did not review Ms. Wettlaufer’s  entire disciplinary file with the ONA Labour Relations Officer, but instead highlighted the more recent disciplinary and non-disciplinary matters. She refused to answer, when pressed, whether she herself believed that Ms. Wettlaufer was a risk to residents at the time of the step 2 meeting.

The decision to terminate Ms. Wettlaufer’s employment was made the morning of March 31, 2014. Ms. Sanganesi testified to a series of email communications between herself, Carol Hepting (Caressant Care VP of Operations), Tim Dengate and Jim Lavelle (Caressant Care CEO). In those emails, Carol Hepting said she believed that Ms. Wettlaufer appeared to be a danger to residents’ welfare. Mr. Dengate concurred that her actions were dangerous. This information was not passed along to ONA’s Labour Relations Officer. Of note, in those emails, Carol Hepting mentioned that in the past, nurses had been permitted to work double and even triple shifts.

Ms. Hughes questioned Ms. Sanganesi on her assessment that there was a 50-per-cent chance that Ms. Wettlaufer would be reinstated through the grievance arbitration process.  Ms. Sanganesi affirmed that labour arbitrators are experienced, that they hear evidence given under oath, make findings of fact based on that evidence and that they are required to consider all relevant statutes and factors, including resident safety.

Ms. Sanganesi also confirmed that she personally drafted the reference letter, with input from Brenda Van Quaethem. While she claimed that the ONA Labour Relations Officer had refused a letter that only referenced Ms. Wettlaufer’s duties as a registered nurse at Caressant Care Woodstock, she did not dispute that she drafted the letter or that once drafted, no changes were made. She also agreed that Sandra Fluttert, the Assistant Director of Nursing and a member of the management team, had verbally provided a “glowing” reference to both Meadow Park and Lifeguard. She confirmed that Ms. Fluttert’s references were not consistent with the written reference letter.

Finally, Ms. Sanganesi was cross-examined on her previous testimony that Ms. Wettlaufer had worked seven shifts in a row. She had noted that this was Ms. Wettlaufer’s choice and she could have refused some of those shifts. Ms. Hughes brought her attention to a meeting note in which EW was strongly encouraged to “step up” to work overtime, after which Ms. Wettlaufer worked the seven shifts in a row.  Ms. Sanganesi continued to insist that Ms. Wettlaufer could have refused to work the additional shifts.

ONA called on Labour Relations Officer, Jill Allingham, to testify. Ms. Allingham was the Labour Relations Officer assigned to Caressant Care Woodstock and filed two grievances at the request of Ms. Wettlaufer: a grievance regarding the five-day suspension imposed in January 2014, and a grievance regarding the termination of her employment.

Ms. Allingham testified that as a trade union, ONA is required to ensure that its representation of members is not discriminatory, arbitrary or in bad faith. In order to not be arbitrary, the union is required to conduct an investigation into the allegations made against the member before deciding whether it will or will not pursue a matter. In this case, Ms. Allingham filed a grievance challenging the five-day suspension and then proceeded to investigate to determine whether or not the file should be referred to arbitration.

As part of her investigation, the Labour Relations Officer asked Ms. Wettlaufer to complete a fact sheet and asked the employer to send her a complete copy of the human resources file so that she could understand the history of Ms. Wettlaufer’s employment with Caressant Care.

Ms. Allingham testified that she did not receive the human resources file prior to the step 2 meeting, which was held on March 12, 2014. That meeting was held by phone because of bad weather. Ms. Allingham testified that she was advised that there had been recent issues with Ms. Wettlaufer’s performance, was provided with some minimal details about the most recent issues, but was not given any documentation relating to those incidents.

Following the step 2 meeting, Ms. Allingham emailed Ms. Wettlaufer, advising that once she received the human resources file they would need to meet to review it, and then they would meet again with the employer.

Ms. Allingham received the HR file two days later. It contained 10 “disciplinary action forms” which included counseling, verbal and written warnings dating back to 2011. It also contained two non-disciplinary letters. It did not contain any of the 30 other incidents. The forms did not contain many details, and, as Ms. Sanganesi had testified, the employer would not provide investigation notes until a grievance had been referred to arbitration and a production order received.

Before Ms. Allingham could proceed with her investigation, Ms. Wettlaufer’s employment was terminated. Following the termination meeting, she filed a second grievance. Despite filing the grievance, Ms. Allingham advised Ms. Sanganesi that Ms. Wettlaufer was not interested in reinstatement and a discussion was held around a possible resolution to the grievance. According to Ms. Allingham’s notes, Ms. Sanganesi was going to look at whether they could provide Ms. Wettlaufer with a “fresh start.”

With respect to the settlement discussions, Ms. Allingham testified that she likely asked for a reference letter setting out something positive about EW. She denied that there was a conversation around a letter setting out only the duties performed by EW. She also confirmed that she did not write any of the content of the reference letter and did not make any changes to that letter once it was drafted by Ms. Sanganesi. Ms. Allingham did not expect the employer to say anything in the letter that was not true and testified that she had no reason to not believe that the comments in the letter – including that Ms. Wettlaufer was punctual, enjoyed sharing her knowledge with others and had good communication skills – were not true.

Ms. Allingham then endured a lengthy cross-examination from counsel for Caressant Care Woodstock.  She was challenged on the fact that she filed a grievance immediately, rather than waiting to investigate. He suggested that each of the incidents in the personnel file were all serious and represented risk to residents.

Ms. Allingham testified that she filed the grievance and was doing all she could to investigate. She also noted that the disciplinary action forms did not provide the extensive detail about the incidents that are now known. For example, one of the forms indicated that Ms. Wettlaufer received a written warning for failing to follow fall protocol. She did not know, from reviewing that form, that Ms. Wettlaufer had moved a resident who may have had a broken hip, that she had punctured a hematoma with unsterile scissors and not provided care to a resident with a bruised and bleeding finger.

She was also questioned about whether she had consulted with any professional practice specialists so as to understand the underlying concerns of the employer. Ms. Allingham testified that she did not have enough detail to make the consultation meaningful, which was why she was seeking the complete human resources file. It was also the reason she had intended to meet with Ms. Wettlaufer to review the file and then meet again with the employer.

Ms. Allingham also testified that there was no requirement for the employer to provide verbal references consistent with the content of the written letter. In other words, when contacted by a prospective employer, Caressant Care Woodstock could have been honest about their concerns regarding Ms. Wettlaufer.

In re-examination, Ms. Allingham confirmed that she had received both orientation and training through ONA staff meetings. She reiterated that she was investigating the incidents and in fact, would likely not have recommended referral to arbitration of the suspension, grievance given the numerous incidents in Ms. Wettlaufer’s file. In order to ensure her decision was not arbitrary, however, she needed to have some additional information, which she was in the process of gathering at the time of termination.

Ms. Allingham concluded that the employer had all the relevant information in their possession and that written and verbal warnings did not reflect that there were serious concerns representing risk to residents.

Wednesday June 20

On June 20, Melanie Smith, the co-director of care at Meadow Park, testified. Ms. Smith’s evidence covered much of the same ground as that of Heather Nicholas, although she was not involved in the decision to hire Ms. Wettlaufer.

Ms. Smith confirmed that the acuity of Meadow Park residents had increased, that their condition was more complex and behaviours more challenging.

The Commission then heard from Wanda Sanginesi. Ms. Sanginesi was the Vice-President of Labour Relations at the corporate head office of Caressant Care.

Ms. Sanginesi testified that she had been consulted by Brenda Van Quaethem and Helen Crombez in 2013 and 2014 in regards to the issues they were having with Ms. Wettlaufer. She reviewed the principle of progressive discipline and stated that she had advised them that they should impose the five-day suspension in April 2013 and again in January 2014.

Ms. Sanginesi confirmed that ONA filed grievances for both five-day suspensions, that the first grievance was withdrawn at the request of the grievor, and the second proceeded to a step-2 meeting.

Ms. Sanginesi testified regarding her recollection of the step-2 meeting, and also confirmed that she provided ONA with a copy of Ms. Wettlaufer’s personnel file two days after the step-2 meeting – more than one month after ONA first requested the file.

Approximately two weeks after the step-2 meeting, and before any further steps were taken with respect to the grievance, Ms. Wettlaufer’s employment was terminated. The decision to terminate her employment was approved by the CEO. In making that decision, it was noted that Ms. Wettlaufer’s conduct was dangerous to the residents.

Ms. Sanginesi then testified to the settlement discussions between ONA and Caressant Care Woodstock led to an agreement to pay Ms. Wettlaufer $2,000 and to provide her with a letter of reference. That settlement was signed in June 2014, six weeks after Ms. Wettlaufer had been hired to work at Meadow Park.

Ms. Sanginesi confirmed that she drafted the reference letter, that she consulted with Brenda Van Quaethem to provide some positive comments about Ms. Wettlaufer, and that no changes were made to the draft letter by ONA.

Tuesday June 19

The Commission heard testimony from Heather Nicholas, the Director of Nursing at Meadow Park, the Long-Term Care Home that hired Elizabeth Wettlaufer after she was fired from Caressant Care Woodstock.

Ms. Wettlaufer worked at this facility from April 2014 until she suddenly resigned in late-October 2014.  During that time, she murdered Arpad Horvath.

Ms. Nicholas testified that she interviewed and hired Ms. Wettlaufer, noting that when she interviewed her, Ms. Wefflaufer was honest, advising Ms. Nicholas that she had made a medication error involving insulin at Caressant Care Woodstock. Ms. Wettlaufer also wrote on her application form that she had been dismissed from Caressant Care Woodstock.

Despite this information, Ms. Nicholas decided to hire her, after checking with two references: one from Christian Horizons and one from Sandra Fluttert, Caressant Care’s Assistant Director of Nursing.

Despite reports by the media, no reference letter arising from a grievance was ever used by an employer in their decision to hire Ms. Wettlaufer.

Ms. Nicholas testified that she did not rely on a letter of reference from Caressant Care Woodstock in her decision to hire Ms. Wettlaufer. The letter of reference, written by the Vice-President of corporate HR for Caressant Care, was written a full six weeks after Ms. Wettlaufer had been hired by Meadow Park.

Ms. Fluttert described Ms. Wettlaufer as a good nurse and noted that other nurses had also been involved in the insulin medication error. Ms. Nicholas had Ms. Wettlaufer take a short test on medications from the College of Nurses of Ontario website, on which Ms. Wettlaufer scored 100%.

Ms. Nicholas testified that the only real issue they had with Ms. Wettlaufer during her time at Meadow Park was a concern over her attendance. They had no concerns with her practice. However, on September 16, 2014, Felina Cabrera, RN, filed a complaint about Ms. Wettlaufer, saying she was not completing her tasks during the evening shift and was instead leaving them for her to complete on the night shift.

Before Meadow Park could investigate, Ms. Wettlaufer sent a resignation letter on September 25, 2014 advising that she was ill, would be seeking treatment for her illness and would be unable to work as a nurse following her treatment.

Ms. Nicholas did not follow up on these comments and did not contact the College of Nurses of Ontario to ask whether a report should be filed. Ms. Wettlaufer worked her last shift on September 26, 2014.

Although she had provided two weeks’ notice, she advised Ms. Nicholas that she was unable to work because she had been hospitalized due to an overdose. At around the same time, Meadow Park became aware that narcotics were missing. The police investigated and although there was a strong suspicion that Ms. Wettlaufer had stolen the narcotics, there was insufficient evidence with which to charge her.

At the inquiry, Ms. Nicholas testified that she did not advise the College of Nurses of Ontario about Ms. Wettlaufer’s resignation, the stolen drugs or Ms. Wettlaufer’s admission that she had been hospitalized due to an overdose.

She also testified that she had had no concerns about Ms. Wettlaufer’s capacity or competence.

Monday, June 18, 2018

On Monday June 18, the Inquiry heard evidence from Laura Long, who was employed as an RPN at Caressant Care Woodstock. Ms. Long described her duties as the RAI Coordinator and confirmed that residents are more complex and that at times, she was required to contact an RN for advice. Like other witnesses, she said that, generally, Elizabeth Wettlaufer was kind to residents, and would bring in food for staff and residents.

Ms. Long was aware that Elizabeth Wettlaufer did have some health issues, and knew that she was on Seroquel. She testified that she had heard once that Helen Crombez had been worried about Wettlaufer when she was changing her medications and sent the police to Ms. Wettlaufer’s home to check on her.

Ms. Long recounted an incident in which she heard Ms. Wettlaufer yelling at a resident, which she reported to the Director of Nursing. She also commented that at times, Wettlaufer was sexually inappropriate and would “hit on” students.

Ms. Long also noted that one Halloween, Ms. Wettlaufer dressed as the Grim Reaper. In cross-examination, she confirmed that this was not an appropriate costume for a party held at a long-term care home where there were palliative patients.

Following Ms. Long’s testimony, ONA brought two motions. The first was to request that several documents from ONA’s grievance files be admitted as relevant. While many documents relating to the settlement of the termination grievance had been disclosed by ONA prior to the commencement of the Inquiry, other documents had inadvertently not been disclosed. Commission Counsel and the Participating Parties discussed a process to ensure fairness so that if any questions arose from the newly disclosed documents for witnesses who had already testified, answers could be sought.

ONA’s second motion was to increase its allotment of time during the Facilities phase. ONA had been provided with five hours for the Facilities phase, which is scheduled to continue until June 28. Given the issues and questions that have arisen about the role of the union at Caressant Care, and the need for ONA to call its own witness, Jill Allingham, to testify as to the settlement of the termination grievance, ONA was concerned that it might require more time. It requested an additional 90 minutes. Counsel for Caressant Care Woodstock and Meadow Park opposed ONA’s request, while other parties, including Ontario Association of Residents' Councils and the Registered Nurses’ Association of Ontario, supported ONA’s request.

Commissioner Gillese allowed the motion and granted ONA an additional 90 minutes’ time, to be used if necessary. In so doing, she acknowledged that sometimes issues within an inquiry get more attention than anticipated – both in the inquiry and outside. The extra time allotted was to recognize that labour issues have taken on a bigger life than might have been anticipated at the start of the proceeding. She also recognized the need to ensure that a balanced perspective was presented.

The hearing is to continue June 19, 2018 with the Director of Nursing, Heather Nicholas, from Meadow Park, testifying.

Thursday, June 14, 2018

Heidi Wilmot-Smith continued to testify on June 14, saying that throughout her employment at Lifeguard, Ms. Wettlaufer worked in numerous agencies including: Revera Telfer Place in Paris; Rykka Anson Place Care Centre in Hagersville; Sienna Fox Ridge Care Community in Brantford; APANs Park Lane Terrace Long-Term Care Center in Paris; Diversicare Hardy Terrace Care Community in Brantford; Revera Briarwood Gardens in Brantford; and Delrose Retirement Residence in Delhi.

During this time, Ms. Wettlaufer attempted to murder a resident in Telfer Place.

There were a variety of issues through her short employment there and three (3) facilities refused to have Ms. Wettlaufer return: Telfer Place, Anson Place and Delrose. Lifeguard made no attempts to end Ms. Wettlaufer’s employment.

On September 7, 2016, Ms. Wettlaufer resigned from Lifeguard effective immediately, citing her inability to practice as an RN. Lifeguard did not report this to the College of Nurses.

Ms. Wilmot-Smith then engaged in a very heated cross-examination by the lawyer representing Revera. The lawyer denied much of the testimony offered by Ms. Wilmot-Smith.

The contract between Lifeguard and Telfer Place dated August 14, 2015 was not signed by Lifeguard.

Revera raised issues with Lifeguard’s orientation process. There was a formal complaint on October 24, 2015 when Ms. Wettlaufer missed her shift completely. Ms. Wettlaufer was drinking that evening, later admitting to Ms. Wilmot-Smith that she had returned to Alcoholics Anonymous. This was not reported to Revera nor the College of Nurses even after she missed a second shift in late December.

Through the cross-examination, it was learned that Heidi Wilmot-Smith – despite sending employees into many long-term care homes – had never read the Long Term Care Homes Act and/or the regulation, nor was she familiar with the requirements of the College of Nurses for employers of RNs and RPNs. Wilmot-Smith admitted she did not know that RNs must have personal liability insurance.

When cross-examined by ONA, the Inquiry heard that Ms. Wettlaufer was paid $36/hour plus statutory payment while the agency billed the agency $65/hour and 8.5 hours for an eight-hour shift. Ms. Wilmot-Smith’s testimony seems to indicate that she viewed Ms. Wettlaufer as an opportunity to “sell” the work of her agency to Caressant Care. This was not successful.

Through ONA’s cross-examination, the Inquiry also learned that Ms. Wilmot-Smith hired Ms. Wettlaufer based only on two verbal references, not the written reference from Caressant Care. Her agency, Lifeguard, did not critically evaluate her application which falsely stated Ms. Wettlaufer’s number of years of RN experience.

ONA member, Agatha Krawczyk, an RN from Caressant Care Woodstock, was the next witness.

She has been employed at Caressant Care since 2003, and testified that, “It is very, very busy in long-term care. It is much busier than the hospital. You have no time for yourself from the first minute that you get there until you leave. I can't take my breaks. No day is the same. Residents have falls, there are families to deal with etc. The day goes by fast.”

Ms. Krawczyk testified to some of the medication practices in the home.

She was the RN who reported the final medication error made by Ms. Wettlaufer that ultimately resulted in her termination, acting very professionally and demonstrating strong leadership in a very difficult situation.

She testified that “Elizabeth Wettlaufer was very friendly with the PSWs. But, in my opinion, there should be limits. You can be nice and friendly but there is a limit.”

Ms. Krawczyk concluded her testimony by saying, “Well, for me, it is still a shock, and I still can't believe it. But I have to say one thing: You know, because of this one person, you know, it doesn't mean that all Caressant Care and all registered staff are – it's so unfair. I have to say I am proud of – that I'm working for Caressant Care as an RN, and I really am telling everybody that Caressant Care is a beautiful home. It is. We have very caring staff. And I don't agree with what I'm reading in the paper.· We have wonderful staff, so...”

The final witness was Brenda Black, PSW. She described the normal work day/workload in Caressant Care Woodstock on the day shift.  She also described how working in a nursing home has changed over time, including the increase in the acuity of the residents.

Ms. Black testified that from her perspective, “we are not spending as much time with the residents as we should.”

Ms. Black worked with Ms.Wettlaufer when she was scheduled on the night shift. She described Ms. Wettlaufer’s behaviour as lazy. “She didn't want to get off her butt,” she said.

Ms. Black reported at least one incident of Ms. Wettlaufer’s inappropriate behavior in 2013.

She testified that the impact of Ms. Wettlaufer's actions: “When this happened, we were flipped upside down. We were locked down for 10 months. We had no new residents. We finally got to the point where we could give care. The residents that remained actually got more care during that time because the staffing was maintained at the same level.”

The Inquiry resumes Monday, June 18, 2018. The next witnesses are an RPN and then a representative of Caressant Care’s Human Resources Department.

Wednesday, June 13, 2018

Karen Routledge returned to continue her testimony on June 13. Ms. Routledge demonstrated her strong leadership and nursing knowledge, especially in the area of long-term care.

She testified that she believed that at most of the discipline meetings she attended with Ms. Wettlaufer, discipline was warranted.  She went on to say that grievances were filed for the last two disciplines – the five-day suspension and termination – in order to enable the Union to obtain more information and ensure that Ms. Wettlaufer was represented. She was not involved in the settlement because she was not the Union representative.

Ms. Routledge confirmed that Caressant Care Woodstock management had not followed the collective agreement to ensure that a Union-appointed representative was available at every discipline meeting.

As for the comments made by another employee that Elizabeth Wettlaufer had told a resident that “it was okay to die.” Ms. Routledge said she believes that the comment was only appropriate for families to say to their loved one. She did recall of  Ms. Wettlaufer being called “the angel of death.”

Ms. Routledge was asked questions about the unexpected death of Maureen Pickering and her call to the coroner’s office. It was the coroner’s decision to not to perform an autopsy.

Personal Support Worker (PSW) Wendy MacKnott was the next witness. She described the normal work day/workload in Caressant Care Woodstock on the day shift. Ms. MacKnott worked with Ms. Wettlaufer when she worked the night shift.

Ms. MacKnott described Ms. Wettlaufer as an odd duck who could be inappropriate sometimes.  She reported Ms. Wettlaufer following a resident fall and what she believed were inappropriate actions for an RN.  Elizabeth Wettlaufer got the resident back to bed by herself instead of waiting for two people and a lift and before she completed a full assessment.  Ms. Wettlaufer then burst a new hematoma with unsterile scissors.  On the same night, Ms. Wettlaufer did not follow up with an assessment on another resident who had a bleeding hand.

Ms. MacKnott also reported Ms. Wettlaufer in April 2013 after an inappropriate, bullying comment was made to a male resident.

Ms. MacKnott testified that she did not suspect Ms. Wettlaufer of causing intentional harm to the residents. “I love my job and I am proud of the work that we do, so it hurts when people say, ‘How can you work at Caressant Care?’” she said.

Ms. MacKnott noted in testimony she wished there could be more staff as everyone is so overworked they cannot give enough care and attention to the residents.

The final witness of the day was Heidi Wilmot-Smith, president and part owner of Lifeguard Homecare Inc. ("Lifeguard").  Lifeguard is a private agency that offers registered staffing support to various facilities, including long-term care homes and private residents' homes. It employs RNs, RPNs and PSWs for these purposes.

Ms. Wettlaufer applied for a position at Lifeguard by email on January 26, 2015. Her resume indicated that she had been employed with Meadow Park since 2014 with no end date. Lifeguard was in significant need of RNs with experience in long-term care. Ms. Wilmot-Smith testified that she was interested in her work experience in long-term care facilities, and did speak to Ms. Wettlaufer about her position with Caressant Care.

Ms. Wilmot-Smith testified that she did call Ms. Wettlaufer's references. Only two responded, one from the time she worked as a Support Worker and the other an ADON from Caressant Care.

After hiring Ms. Wettlaufer, she had a conversation with Carol Hepting of Caressant Care about their potential staffing needs. She thought that since Ms. Wettlaufer had previously worked at Caressant Care, she would be a good fit to be placed in that facility, since there would be no orientation required. Ms. Hepting confirmed they would not be interested in having Ms. Wettlaufer back but declined a request for any further details.  Ms. Wilmot-Smith did not question why.

Tuesday, June 12, 2018

On June 12, the cross-examination of Caressant Care’s Director of Resident Care, Helen Crombez continued. ONA counsel asked hard-hitting questions about her hiring practices, in particular with regard to Elizabeth Wettlaufer.

Noting that the test to terminate employment during the probationary period is much easier for an employer, ONA also asked why Ms. Wettlaufer successfully completed probation based on practice issues that arose during probation.

It was clear that Caressant Care's "progressive discipline" process was flawed.

Ms. Crombez admitted that ONA did not aggressively grieve Elizabeth Wettlaufer's discipline. ONA grieved: one five-day suspension that was quickly withdrawn, and another five-day suspension and her termination. A minimal settlement was achieved by ONA including a reference letter written by the Caressant Care HR staff.

Ms. Crombez confirmed in her testimony that ONA had used its Professional Practice process at Caressant Care, and that resident acuity had increased significantly over time. She testified that both more RNs and more staffing is required.

Now-retired RN, Karen Routledge, (who was also ONA's Bargaining Unit President for two years) testified on June 12 as well.

Ms. Routledge testified about the workload in the home, also saying that more RNs and higher staffing is required. She said there is duplication in paperwork that takes time away from important patient care.

At times, Ms. Routledge attended meetings as the Bargaining Unit President with Ms. Wettlaufer. No grievances were filed.

At other times, Ms. Routledge and other RNs served only as ‘witnesses’ when Ms. Wettlaufer received additional discipline and counseling. They were not ONA representatives at that time.

Ms. Routledge testified about the administration of insulin in the home during the time of Ms. Wettlaufer's actions. She admitted to being stunned and devastated when she learned of Ms. Wettlaufer's actions.

Monday, June 11, 2018

On Monday, June 11, the legal counsel for a group of victims and their families cross-examined Helen Crombez, Caressant Care’s former director of nursing.

Alex Van Kralingen questioned Ms. Crombez on Caressant Care Woodstock's failure to file reports with the Ministry of Health and Long-Term Care, as required. The inquiry heard that Caressant Care failed to report to the ministry on several occasions, including:

  1. October 2007, when a nurse charted that a resident had very low blood sugar. When the nurse called the physician, he replied that another nurse had already called and reported an insulin overdose. The patient was then sent to the hospital. Ms. Wettlaufer was working the shift when the call was made to the physician about the overdose. Although the reporting nurse filed an incident report, reporting the medication error, no report was filed with the hospital, despite the fact that the patient was hospitalized as a result of the insulin overdose. Ms. Wettlaufer was later convicted of aggravated assaulted related to this resident
  2. Caressant Care did not report the death of another resident, Mr. Silcox, to the Ministry of Health and Long-Term Care, despite his death being noted as "sudden and unexpected" and "accidental" in the report to the coroner.

Ms. Crombez also confirmed that despite the fact that Caressant Care corporate head office approved the installation of a camera in the medication room (following the theft of narcotics), it "just didn't happen."

ONA cross-examination

ONA legal counsel Kate Hughes then cross-examined Ms. Crombez. Ms. Crombez testified that she was aware that Elizabeth Wettlaufer had discussed her own significant health concerns, including the fact that she was changing her medication and having difficulty adjusting to that change. Ms. Crombez testified that she never followed up with Ms. Wettlaufer to determine whether her health issues impacted her ability to work.

The director of nursing also testified that she witnessed Ms. Wettlaufer stumble once, and was concerned that she was having what she described as an "episode;" however, she took no action other than asking the nurse whether she was okay.

Ms. Crombez also testified that she threatened to file a report to the College of Nurses of Ontario regarding Ms. Wettlaufer’s health issues, but that she never did so.

At Caressant Care, nurses filed multiple Professional Responsibility Clause forms raising concerns about workload and staffing issues in this home, particularly when they were required to work short on night shifts.

Ms. Crombez agreed that Caressant Care needed more nurses, and she estimated that each nurse was required to care for 20 patients.

Jane Meadus, speaking on behalf of the Ontario Association of Residents Councils, said that staffing the home during a night shift with two registered practical nurses was not equal to having one registered nurse.

Ms. Crombez also testified that any physical changes to the home’s environment, such as installing larger windows in the medication room, would not make any difference to the security of medications if there was no staff there to actually look into the room.

Friday, June 8, 2018

Caressant Care Director of Nursing, Helen Crombez, testified.

Ms. Crombez had been the Director of Nursing for approximately 30 years and knew Elizabeth Wettlaufer well.

Ms. Crombez testified about medication administration practices in the home, including the ordering, administration and destruction of narcotics, non-narcotic medications, and insulin.

She reviewed many of the more than 40 incidents that involved Ms. Wettlaufer, ranging from personality conflicts, odd behaviour, medication errors and practice issues.

Although Ms. Crombez repeatedly described Ms. Wettlaufer's conduct and practice as inappropriate, she said she did not impose harsher discipline, in part because Ms. Wettlaufer always took responsibility for her errors and apologized.

The Director of Nursing confirmed that neither she nor the home filed any reports to the MOHLTC to report neglect or abuse of patients because she "probably didn't think of it."

Ms. Crombez said she was not concerned about ONA.

ONA will cross-examine Ms. Crombez on June 11.

June 7, 2018

On Thursday, June 7, Caressant Care administrator Brenda Van Quaethem was cross-examined.

Under questioning by Paul Scott, counsel for some of the victims’ families, Ms. Van Quaethem confirmed that she was not comfortable with the low nurse staffing levels. She confirmed for the inquiry that even if an RN had just 10 residents to care for, they would still be busy.

Elizabeth Wettlaufer was directly responsible for 32 patients during the day and if she worked the night shift, she had responsibility for 82.

ONA counsel Kate Hughes cross-examined the administrator on a number of key issues related to the union.

Ms. Van Quaethem admitted that she never looked at Ms. Wettlaufer’s discipline file as a whole. She never reviewed any disciplines in 2007 and 2008, which was prior to her time as administrator. She also said she would only glance back at the file to see what level of discipline had been previously administered.

At no time did she ever look at Ms. Wettlaufer’s file as a whole, looking for a pattern.

Ms. Van Quaethem confirmed that she did not follow the ONA collective agreement. She was unaware that there was an 18-month sunset clause, instead assuming that it was one year, as it was in the Unifor collective agreement.

Although the administrator had indicated earlier in cross-examination to Paul Scott that had there not been a union, she might have terminated Ms. Wettlaufer earlier because of the financial cost to a settlement, she subsequently admitted that the decision to discipline and terminate an employee is a unilateral management decision.

ONA challenged her evidence that any settlement funds would come out of the Nursing and Personal Care [funding] Envelope. It is now on the record that ONA believes it comes from the "Other Accommodation" envelope, which is the envelope from which for-profit homes take their profit.

Importantly, the administrator admitted that ONA did not know about many of the issues involving Ms. Wettlaufer, that ONA was not aware of many of the disciplines and was not aware of the critical incident reports that were filed.

ONA was also not aware that narcotics were missing. In other words, the home did not share information with ONA – the home’s management held all the pieces of the Wettlaufer puzzle, and ONA did not.

June 6, 2018

The first witness was called to testify on June 6. Brenda Van Quaethem was the administrator of Caressant Care Woodstock, where the majority of Ms. Wettlaufer’s offences occurred (seven murders, two aggravated assaults and two attempted murders).

The Commission heard of Ms. Van Quaethem’s professional history – a former ‘nurses’ aid’ she testified that she had little training in her role. ONA notes that Ms. Van Quaethem’s background included little or no training in human resources and she was not a health-care professional. When asked what training Caressant Care’s corporate head office provided to her, she said none.

She confirmed that it is difficult to recruit and retain RNs to work in long-term care, and that Caressant Care was short of RNs the entire time she was administrator (2009-2016). It was noted that Ms. Wettlaufer had, at one point, worked seven shifts in a row; Van Quaethem stated that staff were required to work seven shifts in a row “a fair enough number of times” because of the home was short staffed.

She provided evidence of the fact that patient acuity has been rising and that the needs of residents were much more complex than they were in the past. Most residents are no longer independent – they are in wheelchairs or use walkers.

Ms. Van Quaethem reviewed Ms. Wettlaufer’s lengthy disciplinary history. She testified that during her seven years working at Caressant Care, she had been counseled on many occasions, had received multiple verbal and written warnings, was suspended several times and was ultimately terminated. The disciplines were imposed for a multitude of offences, including inappropriate communications and interactions with staff and residents, medication errors, and attendance issues.

Ms. Van Quaethem testified that on several occasions, the employer did not impose any discipline or counseling despite receiving complaints from staff. On those occasions, they may have spoken to Ms. Wettlaufer but did not take any action.

She testified that the decision to impose a suspension or termination needed to be vetted through Caressant Care’s Head Office.

Participating Parties will have the opportunity to cross-examine the former administrator on June 7.

June 5, 2018

The Long-Term Care Inquiry began on Tuesday, June 5, 2018 with the participating parties, including ONA, introducing themselves and indicating their interest in the proceeding.

ONA indicated that it is participating in order to ensure that a tragedy like this never occurs again. ONA noted that Elizabeth Wettlaufer’s conduct was an aberration, and that long-term care nurses are passionate and dedicated professionals who choose to work in this sector despite the many systemic challenges. These include chronic understaffing and underfunding, made more problematic at a time when resident acuity is increasing.

ONA will be advocating for systemic changes to ensure the highest level of resident care and safety.

Commission counsel briefly reviewed the facts of the crimes committed and provided details of each of the 14 victims (eight residents were murdered, there were attempted murders and two aggravated assaults). Ms. Wettlaufer’s early career was reviewed, including her brief period of employment at Geraldton District Hospital. She was terminated from the hospital for stealing medication.


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