Wettlaufer murders still a 'horrific puzzle' that inquiry could help solve

Elizabeth Wettlaufer, the former nurse who killed instead of cared for her elderly patients, was sentenced Monday to life behind bars, but the story of how she carried out her crimes is far from over, and it's one still shrouded in mystery and secrecy.

Soon after Wettlaufer left the courthouse in Woodstock, the small Ontario town where she committed most of the murders, provincial Attorney General Yasir Naqvi and Minister of Health and Long-term Care Eric Hoskins announced a public inquiry.

"It is our hope that through the inquiry process, we will get the answers we need to help ensure that a tragedy such as this does not happen again," they said in a statement.

But how did it happen in the first place? Wettlaufer lethally overdosed eight residents of long-term care homes with insulin, and tried to kill four others. She did it over the course of seven years, with no one noticing.

Police were only alerted to her crimes in September when Wettlaufer checked herself into the Centre for Addiction and Mental Health (CAMH) in Toronto and began telling staff there what she had done. They then called police. Wettlaufer confessed, was charged with murder, attempted murder and aggravated assault, and pleaded guilty earlier this month.

It was not the first time she had confessed. Over the years, she told her pastor, a lawyer and several others, but no one acted on it.

Doris Grinspun, head of the Registered Nurses' Association of Ontario, said in an interview that "alarm bells went on that were not answered," and an inquiry will help determine why they were ignored.

Missing pieces

"We need to understand how exactly we got to have eight lives lost from absolutely all the perspectives so we can put this horrific puzzle together," said Grinspun.

Some of the puzzle pieces come from the 50-year-old serial killer herself — in her confession tape with police and from their investigation. Other details came to light through court proceedings. But there are many gaps in Wettlaufer's story and lingering questions about her troubled life and career. Her guilty plea meant there was no trial to help answer them.

"Start the thing tomorrow," Andrea Silcox, whose father James was Wettlaufer's first murder victim, said about the need for a public inquiry. Silcox said outside the courtroom Monday that Wettlaufer is not the only one to blame for what happened.

A public inquiry is not meant to assign blame but to establish facts and make recommendations.

It can, however, compel witnesses to testify and gather evidence, and that should help address some of the key questions which have so far gone unanswered by Wettlaufer's former employers and the College of Nurses of Ontario.

Among them:

- Why did it take Caressant Care, the nursing home in Woodstock where she began killing, so long to fire Wettlaufer when she repeatedly made mistakes that put patients at risk?

- How did the College of Nurses handle the mandatory report it got from Caressant Care about her termination in 2014?

- Did it investigate Wettlaufer then and, if not, why not? If it did, what happened next?

- How did Wettlaufer get one job after another despite her blemished record as a nurse? (In addition to getting fired, she had restrictions on her licence early in her career.)

These questions and many more were put to Wettlaufer's employers and to the college by CBC News. They declined interviews. Some answered select questions by email.

Reference letter mystery

Caressant Care said it co-operated with police and will support any further investigations but wouldn't say whether they checked references when they hired Wettlaufer in June 2007.

Before Caressant, she worked as a personal support worker, not a nurse, at Christian Horizons, a facility for people with disabilities. Police documents say she had a reference letter from them.

But Cindy Winegarden, public relations manager at Christian Horizons, told CBC it's not their practice to write reference letters for departing employees.

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Winegarden said Wettlaufer started worked there in June 1996 and quit in June 2007 "to pursue her career in nursing."

She started with Caressant that same month and it wasn't long before she was misusing insulin to harm patients. She committed her first murder by mid-August.

Wettlaufer didn't have a spotless record during her seven years at Caressant Care. It suspended her multiple times for making mistakes with medication and then fired her after yet another error that put a patient's life at risk.

Caressant Care reported that, as required, to the College of Nurses in a letter dated April 17, 2014. It took the college three months to send a letter back acknowledging they received it.

College of Nurses too 'secretive'

The college says it is committed to responding quickly when it gets information about patient safety being put at risk but it will shed no light on what response it took to Wettlaufer.

"While we cannot speak to this specific case, it is the college's process to inquire into all mandatory reports," Deborah Jones, director of communications, said in an email.

Jane Meadus, a lawyer with the Advocacy Centre for the Elderly, is frustrated by the lack of information from the college. How it handled that report is "a really big question," she said in an interview.

"There are a lot of things that really are kept quite secretive there," said Meadus.

What the college will say is that it launched an investigation into Wettlaufer on Sept. 30, 2016, after she contacted them to confess she killed patients and to resign her licence.

A discipline hearing is scheduled for July 25 and at that time Wettlaufer's regulatory history will become public.

For now, Jones says the college is bound by the Regulated Health Professions Act to keep information confidential with limited exceptions. The college says it is pushing the government for changes to that law so that it's able to share more information publicly.

Jones said the college also can't answer questions about Wettlaufer because doing so would "risk the integrity" of the case before the discipline committee.

When it comes to Wettlaufer's regulatory history, it appears she had been in trouble with the college before, not long after she first registered with them in 1995 upon graduating from nursing school.

There are indications that early in her career, restrictions were put on Wettlaufer's nursing licence due to overdosing on hospital medication while at work, and that's partly why she was a personal support worker instead of a nurse for a period of time. Details about those early days of her career are scarce.

Licence trouble early on

Geraldton District Hospital, in northern Ontario, confirmed that Wettlaufer worked there as a student nurse for four months and that they hired her when she graduated.

Her first job as a registered nurse lasted only three months. The hospital won't say why Wettlaufer left in September 1995, citing privacy laws.

That may or may not be where an overdosing incident occurred. The college wouldn't confirm any specifics about any licence restrictions in those early years.

"In general, historical information about incapacity issues, which includes substance abuse as well as physical and mental health issues, are not part of the public register," Jones responded when asked why a previous restriction on Wettlaufer's licence would not be listed on the college's online Find a Nurse registry.

That's where the public can see a nurse's history with the college, including information about their ability to practice.

Prior to 2009, that kind of information would be removed from the registry after six years. But the rules were changed so it's on the registry permanently "unless it was no longer in the public interest to publish the information," Jones wrote.

Wettlaufer struggled with addiction to alcohol and opioids and sought help for it over the years. It's why she left her job at Meadow Park nursing home in London, Ont., where she was hired weeks after she was fired from Caressant Care.

In her police confession tape Wettlaufer says Meadow Park found her, she didn't seek it out for work, and that she was honest about why she lost her last job. They told her they believe in second chances, Wettlaufer said, and hired her.

'There is a story here'

Meadow Park is where Wettlaufer murdered her last victim, Arpad Horvath, in August 2014.

Meadow Park's director of long-term care operations, Judy Maltais, outlined the home's hiring practices in an email but wouldn't specify whether they were followed with Wettlaufer, nor would she answer other questions about her employment including whether references were checked.

After Meadow Park, Wettlaufer was hired by a nursing services company called Lifeguard Homecare. Reached by phone and asked how Wettlaufer came to work there, president Heidi Smith said, "That's going to be a very interesting story to be told."

Smith said she's in favour of a public inquiry to "bring light on some of that information."

She said Lifeguard checked two professional references and they were credible and positive, that Wettlaufer's criminal background check was clear and she was in good standing with the college.

"There is a story here, we do look forward to an inquest," said Smith, who was the only representative of a former employer to answer whether it supports a public inquiry. (The College of Nurses said Monday it welcomes the inquiry.)

'Satisfactory references'

The final place Wettlaufer worked was Saint Elizabeth Health Care, a home care provider that employs 8,000 people across Canada.

Madonna Gallo, the media relations executive, said policies were followed when hiring Wettlaufer in July 2016, including checking "satisfactory references" but wouldn't say who they were or anything else about Wettlaufer's employment.

Wettlaufer quit Saint Elizabeth just six weeks later after being told they wanted her to work with diabetic children. She feared she would harm them. Shortly afterwards she checked herself into CAMH.

Loved ones of the victims say they hope their ordeal will lead to changes in long-term care homes so that residents are better protected.

"That's the only good thing that could come out of this," said Laura Jackson, whose friend Maurice Granat was murdered.

Grinspun, of the Registered Nurses' Association, sees how a public inquiry could offer some comfort to the many people suffering because of Wettlaufer.

"The very least we can do to honour and respect the lives lost is to ensure that we do all we can so this doesn't happen again," she said.