Changes coming to death investigations, tracking, chief coroner tells Wettlaufer inquiry

Changes are coming to how the province's 350 local coroners are appointed, the education they get and how their performance is reviewed, Ontario's chief coroner testified Tuesday at the inquiry looking into how serial killer Elizabeth Wettlaufer was able to kill eight patients in her care.

Currently, coroners are appointed for life, there's no mandatory training beyond an initial course and there's no performance review system, Dr. Dirk Huyer told the inquiry, being held at the Elgin County courthouse in St. Thomas, Ont.

The coroners who would have dealt with nurses reporting Wettlaufer's victims' deaths would have only taken a two- or three-day course, Huyer said. The course was lengthened to five-days two or three years ago.

"It's my desire to have a reappointment system that would require continuing education," Huyer testified.

He wants coroners to have to reapply for their jobs every three to five years, and a performance review system. Right now a coroner's work is only reviewed if it's flagged by someone such as a police officer, nurse, or member of the public.

Huyer also wants to change the structure of how coroners are paid for death investigations, he said.

Currently, coroners get $450 for every investigation they perform. Huyer wants them to be paid for the time they take to do an investigation instead of getting paid a flat fee.

Wettlaufer's killing spree lasted from 2007 to 2016, when she checked herself into a psychiatric facility and confessed to eight murders and six attempted murders. Most happened at long-term care facilities in southwestern Ontario.

Some issues with 1 coroner

Since 2006, only two coroners have been removed from their posts after complaints. A third coroner's work is being reviewed, though he or she is not one of the coroners who dealt with any of Wettlaufer's victims.

The coroner's course places emphasis on speaking to family members about their concerns and to paying close attention to deaths that might appear natural that in fact could be more sinister. It also spells out to coroners the need to pay particular attention to deaths among "vulnerable populations," such as people in long-term care.

When Maureen Pickering, a resident at Caressant Care in Woodstock, Ont., died in 2014, a nurse had concerns as did the ER doctor who treated her. At the urging of the doctor, the nurse contacted the coroner, who declined to perform an investigation.

That coroner, Dr. William George, didn't take notes about why he decided against investigating the death.

"It's an expectation that notes be kept whether or not an investigation is done so they can be used in the future to review the reasons as to why" a decision was made, Huyer said.

Local coroners are also told to consult family members if they investigate a death because they're often good sources of information about how a patient was acting prior to death, he added.

George is expected to testify later this week.

Budget cuts decreased investigations

Budget cuts at the coroner's office have meant fewer deaths in nursing homes are investigated, Huyer testified on Monday.

In 2007, more than 3,300 deaths in long-term care were investigated by one of 350 local coroners, compared to 927 in 2015.

The drop is a result of changes to which deaths are investigated, Huyer said.

Until 1995, every death in a nursing home faced a coroner's scrutiny — looking over medical records and ensuring nothing was amiss. Beginning in 1995, every tenth death was investigated.

But in 2013, to save $900,000, the province scrapped those investigations.

Instead, nurses or doctors now fill out a death record form. If a death is "sudden or unexpected," an investigation is started.

Huyer said he didn't know if the increased investigations would have resulted in spotting patterns in nursing homes where Wettlaufer was working.

He also said a planned data analysis of deaths at long-term care homes has been on hold since 2014 because some facilities are not filing death records electronically. Instead, they're using fax.

As well, deaths that happen in hospitals after someone has been transferred from a long-term care home aren't tied to the nursing home.

"Deaths that happen in hospitals may have been from incidents that began within the long-term care home," Huyer said.

It's a change he would like to see made in how deaths are tracked and tabulated, he added.

The inquiry is being held at the Elgin County courthouse and is expected to last until September.