Elizabeth Wettlaufer Murders: Report Shows Gaps in System

The public inquiry into how serial killer, former registered nurse Elizabeth Wettlaufer, got away with her crimes placed the blame on systemic failures. The report includes extensive recommendations to prevent similar tragedies in the future. 

Over the course of a decade, Wettlaufer murdered eight elderly patients with insulin overdoses and attempted to kill further five. No one would have been any the wiser if she hadn’t admitted herself to a psychiatric institution and then confessed. 

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Commission of inquiry into Wettlaufer murders

A public commission was appointed to look into the circumstances surrounding this tragedy in order to determine how Wettlaufer was able to get away with these murders for so long. 

After more than a year since the inquiry started, a lengthy four-volume report detailing the incident was released on July 31. The commission started by conducted public hearings. This was followed by research, obtaining advice from experts, and extensive consultation with those working in long-term care institutions

The majority of nurses, who have the well-being and safety of their patients at heart, have much to learn from the findings and the recommendations contained in the report. 

Report Shows Gaps in System|Main conclusions of Wettlaufer inquiry

In her statement at the official release of the report, Commissioner Eileen Gillese summarized the significant conclusions. 

Wettlaufer’s killings were not mercy killings – the killer described that she felt euphoria afterward. They did it purely for what she got out of it.  Most importantly – no-one can rest assured by the fact that she’s behind bars. Since the 1970’s there have been over 90 serial killers in healthcare across the world – it is a reality that no-one can ignore.

“There would have been no knowledge of THESE offenses without Wettlaufer’s confession.”

The need for long term care will continue to increase as populations get older, and so will the acuity of patients and the workload in caring for them – and the system needs to provide or this.  

The killings did not only hurt the victims and their loved ones. It left the other residents and their families concerned over their own safety and the general public shocked and disturbed. Health care providers were, undeservedly, cast in a bad light and felt guilt and shame that one of their own could have committed such crimes and that they had not prevented it.

The commission found that no one individual was guilty of misconduct – it never crossed anyone’s mind that a healthcare provider would intentionally harm their patients. So why would measures have been put in place to prevent it?

There were, however, vulnerabilities in the system and changes were necessary to avoid similar tragedies in the future. The Commission suggests a four-pronged strategy – prevention, awareness, deterrence, and detection (PADD). Each of these areas has specific recommendations. 

Wettlaufer inquiry recommendations 

Altogether, there are 91 recommendations and their implementation will require communication and co-operation between all the various stakeholders. Some of the suggestions which relate directly to nursing are highlighted below. They can serve as a wake-up call for nurses across the world. 


With regard to prevention, long-term care homes should address the shortage of registered staff and limit and improve the use of agency nurses. They should also provide educational programs to improve employees’ skills as well as opportunities for advancement. 


The Commission suggested that to create awareness of the serial killer phenomenon, government institutions should conduct research and share their findings widely. Key information should be passed on to the institutions that educate health care providers.

The College of Nurses of Ontario (CNO), which is the registering body for nurses, should educate its members about the possibility that there might be nurses who will harm their patients intentionally. This concept should also be included in nursing education programs. Furthermore, the CNO should strengthen its investigation processes, policies and procedures with this fact in mind. 


In terms of deterrence, the Commission recommended that long-term care facilities should strengthen their medication management and incident analysis systems. The government should provide grants for the infrastructure needed to improve medication safety and control. These facilities should employ more registered staff and the government was tasked to determine safe staffing levels and adjust funding accordingly. 

Processes around the screening and hiring of new staff should be stricter.  Proper background checks are necessary, especially if there are any red flags such as gaps in employment history or if the person had been terminated previously. 


Surveillance conducted by the Coroner and the forensic pathology services of deaths in long-term care homes needs to be strengthened.  A new death report form, to be completed by a health care professional who cared for the patient, would have more detailed data. This would allow for analyses to detect trends and clusters of deaths.  

Employers’ reporting to the CNO about nurses who were terminated and around issues of incompetence and incapacity needs to be improved. The CNO should also educate its members about their professional responsibility to report colleagues suspected of abusing and neglecting their patients.  

Portion of long-term care report dedicated to nurses 

Volumes I and II of the inquiry report were dedicated to the victims, their families and loved ones. Volume III, which deals with the strategies to achieve PADD “is dedicated to the many nurses and other caregivers who perform their jobs in the long-term care system with great kindness and skill. Our Strategy for Safety cannot succeed without their continued dedication to those in their care. In opening our eyes to the one nurse who harmed, we must not forget the work of the many who are a credit to their professions.”

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