THURSDAY,AUGUST1,2019 | THEGLOBEANDMAIL O NEWS | A1 1
That is the wimpy, all-too-Canadian conclusion of the
two-year long, four-volume, 1,491-page Public Inquiry
into the Safety and Security of Residents in the Long-
Term Care Homes System.
“Assigning blame to individuals or organizations is
counterproductive,” according to Justice Eileen Gil-
lese, the Ontario Court of Appeal judge who presided
over the inquiry.
Systemic issues, we are told, are “best dealt with by
encouraging people to go down a path where they can
change the things that went wrong.”
Okay, so lest we hurt people’s feelings (or careers)
by talking about what they failed to do in the past,
let’s focus on what they could do better in the future.
The inquiry made 91 recommendations on what
needs to be done to prevent similar tragedies in the
future, including:
Better training for administrators on how to
screen, hire, manage and discipline staff;
Bolstering the medication-administration system
in long-term care homes;
Expanding funding from the Ministry of Health
and Long-Term Care;
Conducting a study to determine adequate staff-
ing levels in long-term care homes.
Bolstering inspections, and giving priority to re-
sponding to “high-risk incidents” such as fatal medi-
cation errors;
More clear reporting requirements for service pro-
viders and staff, both to the ministry and regulatory
colleges and more robust investigations;
Better death records,
and more frequent autop-
sies of patients who die in
long-term care;
Building awareness of
the “health-care serial-kill-
er phenomenon.”
We didn’t need a public
inquiry to tell us that long-
term care homes are grossly underfunded and under-
staffed.
Unfortunately, the inquiry didn’t make any specific
recommendations on how to remedy this, and the
province, in turn, promised nothing but to study the
issue.
The people living in long-term care – 78,667 beds in
626 licensed homes in Ontario alone – are among the
most frail and vulnerable in society. Almost two-
thirds are living with dementia, and most have a mul-
titude of chronic health problems.
Ensuring that patients are not murdered is impor-
tant, obviously.
But also important, and far more relevant, is ensur-
ing that every single patient has quality, hands-on
care every day and every night.
In many institutions, that’s not happening now, to
the point where families are fearful of placing their
loved ones in long-term care.
The Registered Nurses’ Association of Ontario has
proposed that there be mandated staffing ratios: 2 0
per cent registered nurses, 25 per cent registered prac-
tical nurses and 55 per cent personal support workers
and, in addition, one nurse practitioner per 120 resi-
dents.
That would definitely mean better care, but it
would also markedly increase the cost of care.
Those are the tough, bottom-line discussions we
need to have.
Ultimately, it’s about the value we place on the
quality of life of our elders.
Let’s be frank: Elizabeth Wettlaufer was not a so-
phisticated serial killer. Through her actions, she vir-
tually begged to be found out.
The reason she was not caught was not solely be-
cause of the lack of checks and balances, and adminis-
trative/regulatory failures outlined in the report.
It was something more insidious: The people she
killed didn’t much matter because they were old and
sick.
What patients in the long-term care system need to
fear is not individual killers, but a culture of indiffer-
ence that allows inadequate and second-rate care to
be accepted as the norm.
That is not going to change simply by throwing
more money and more bodies into the current sys-
tem.
One of Justice Gillese’s conclusions was that the
“long-term care system is strained, but not broken.”
But many parts of it are broken. Many people and
institutions need to start taking responsibility for that- personal responsibility.
Picard:Manyfamilies
fearfulofplacingloved
onesinlong-termcare
FROMAPeoplelistenasOntarioAppealCourtJusticeEileenGillesediscusseshernearly1,500-page
finalreportintotheprovince’slong-termcaresystem.JusticeGillese’sreportsaysthe
systemis‘strained,butnotbroken.’FREDLUM/THEGLOBEANDMAILFormernurse
Elizabeth
Wettlaufer,seen
belowin2016in
Woodstock,Ont.,
confessedthat
yeartomurdering
eightpatientsand
tryingtokill
severalothers
overnineyears.
GEOFFROBINS/THE
GLOBEANDMAIL
their medication rooms by adding glass
windows, security cameras and bar-code
systems.
Other recommendations include: re-
quiring nursing homes to adopt a hiring
and screening process that
includes robust reference
checks; forcing directors of
nursing to conduct unan-
nounced spot checks on
nights and weekends; re-
quiring homes to keep a
complete discipline history
for all staff; creating a new
official death record that
would be submitted elec-
tronically to the coroner’s
office; and beefing up gov-
ernment inspections, in-
cluding looking more close-
ly at homes with higher-
than-expected mortality
rates.
The Long-Term Care
Homes Public Inquiry exam-
ined more than 42,000 pag-
es of documents and heard
testimony from 50 witnesses over 39 days,
most of it at a courthouse in St. Thomas,
Ont.
During that time, the inquiry heard
how several players in the system missed
opportunities to catch Ms. Wettlaufer, anurse with a disturbing track record of
personal drug abuse, sloppy practices and
conflicts with her colleagues and bosses.
As the report points out, she was driven
to kill by her own unhappiness and rage,
and was in no way a “mercy
killer.”
The seniors that Ms. Wet-
tlaufer was convicted of kill-
ing were Mr. Silcox, Mr. Hor-
vath, Maurice Granat, Gladys
Millard, Helen Matheson,
Mary Zurawinski, Helen
Young and Maureen Picker-
ing. The patients she injected
with overdoses of insulin but
didn’t kill were Sandra Tow-
ler, Clotilde Adriano, Albina
deMedeiros, Wayne Hedges,
Michael Priddle and Beverly
Bertram.
Ms. Bertram, the only re-
maining survivor today, sat
in a wheelchair in the front
row as Justice Gillese pre-
sented her report.
Ms. Wettlaufer attempted
to kill Ms. Bertram in 2016 with an over-
dose of insulin delivered as the nurse
cared for her at her home in Ingersoll, Ont.
“She doesn’t deserve my pity,” Ms. Ber-
tram said of Ms. Wettlaufer, “but I’m sorry
for her.”Manyofthe
recommendations
wouldcost‘littleor
nothingto
implement,’the
reportsaid,butfor
thosechangesthat
requiremore
funding,‘thecostis
proportionaltothe
seriousthreatthat
health-careserial
killerspresentinthe
long-term care
system.’Ultimately,it’sabout
thevalueweplace
onthequalityoflife
ofourelders.