Key recommendations from public inquiry into serial-killer Elizabeth Wettlaufer

A public inquiry examining the case of Elizabeth Wettlaufer, a serial-killer nurse who preyed on elderly patients in her care, has issued a report aimed at preventing such crimes in the future. Here are some key recommendations from the 91 listed in the report:

• The government of Ontario should ensure that a strategic plan is in place to build awareness of the health-care serial killer phenomenon.
• The Ministry of Health and Long-Term Care should create new, permanent funding for long-term care homes for training, education, and professional development for those caring for residents.
• The ministry should expand the parameters of the funding it gives homes for nursing and personal care to allow them to spend it on a broader spectrum of staff, including pharmacists and pharmacy technicians.
• It should create a three-year program under which homes can apply for grants of $50,000 to $200,000, based on their size, to improve visibility and tracking of medication.
• The ministry should refine its performance assessment program for long-term care facilities to better identify those struggling to provide a safe and secure environment.
• It should conduct a study to determine adequate levels of registered nursing staff in long-term care facilities and table the findings by July 31, 2020. If the study shows a need for additional staffing to ensure residents' safety, homes should receive more government funding.
• Long-term care homes should analyze medication-related incidents and adverse drug events through a framework that includes screening for possible intentional harm.
• Homes should document and track the use of glucagon, a hormone that raises a person's blood sugar, to identify patterns and trends.
• Facilities should require that directors of nursing conduct unannounced spot checks on evening and night shifts, including weekends.
• Homes must maintain a complete discipline history for each employee so management can easily review it while making discipline decisions.
• The Office of the Chief Coroner and the Ontario Forensic Pathology Service should replace the current form submitted when a long-term care patient dies with a redesigned, evidence-based death record that includes whether aspects of the resident's decline or death were inconsistent with the expected medical trajectory.
• They should also develop protocols on the involvement of forensic pathologists in death investigations of long-term care residents, as well as a standardized protocol for autopsies performed on the elderly.
• The College of Nurses of Ontario should revise its policies and procedures to reflect the possibility that a health-care provider might intentionally harm those in their care.