Wettlaufer inquiry reveals series of failures to protect elderly victims

A public inquiry looking into how Elizabeth Wettlaufer's crimes went undetected for a decadebegan hearing testimonythis past weekthat warning signs about the nurse's conduct were repeatedly swept "under the table."

The crimes began in 2007 and continued to 2016when Wettlauferfinally confessed to police. Until then, her employers, police and Ontario's licensing body for nurses had no idea eight patients had been murdered and sixmore poisoned all with injections of massive doses of insulin.

"Why was she able to get away with this undetected?" asked Mark Zigler, the co-lead counsel for the public inquiry in St. Thomas, Ont., which willlast four months and release its recommendationsnext summer.

Already, a series of startling revelations is highlighting how a health care system that was supposed to protect the elderly and vulnerablemay have failed them.

Union protectedWettlaufer, witness testifies

The inquiry's first witness was Brenda Van Quaethem the administrator at the Carressant Care long-term care facility in Woodstock, Ont. That's where Wettlaufer has since admitted to killing seven of her eight victims.

She detailed at least nineseparate occasions where Wettlaufer was suspended or admonished for making medication errors, abusing a patient and staff.

But she accused Wettlaufer's union of making it difficult to sanction or terminate herbecause the Ontario Nurses Association would grieve her suspensions and terminations.

"It was cheaper," she said, not to fight the union. She pointed out that Carressant Care had to reimburse Wettlaufer for prior suspensions and pay $2,000 in "damages" when itfinally terminated her employment in 2014.

The inquiry has heard that Carressant Care found it difficult to recruit and retain registered nurses due to nursing shortages.

Alex Van Kralingen, the lawyer representing four of the victim's families, calls the testimony troubling.

"A nurse who should not have been there, or who in any other circumstance may have been terminated much earlier, was allowed to stay simply because there were repercussions of not having any nurse there in the environment at the time," said Kralingen.

The inquiry was also told CarressantCare had increasing concerns about Wettlaufer. In August 2012, the home threatened to report her to the College of Nurses of Ontario for a "fitness to practise" hearing that could have put an end to Wettlaufer'scareer.

The facilitydidn't followthrough.

Licensing body decided not to revoke Wettlaufer's licence

The College of Nurses of Ontario said CarressantCare had reported her termination to the licensing body in April 2014 shortly after she was fired.

The college was also provided with a list of hertransgressions.

Yet Wettlaufer'slicence was neither suspended norrevoked.

Instead, she went on to find work at the Meadow Park care home in London, Ont.,where she killedArpad Horvath, 75. She also tried to kill two more patients while working for health care agencies in Ingersoll, Ont., and Paris, Ont.

Representatives of the union and college are expected to testify in the coming days and weeks.

First death unexpected,but no autopsy

James Silcox, a Second World Warveteran, was the first of Wettlaufer's victims. He was murdered at Carressant Care in 2007.

Documents reveal the local coroner was advised his death was unexpected, yet no autopsy was performed that mighthave detectedan insulin overdose.

Silcox's daughter Andrea says the system failed all of the victims.

"This wasn't the fault of one person;this was the fault of the system," she told CBCNews.

"It wasn't just Wettlaufer that is to blame for this whole thing. She was given the opportunity to do these things by people brushing her previous issues under the table."