What Ontario knew, Part 4: An inquiry into a serial murderer — and long-term care

ANALYSIS: Justice Eileen E. Gillese was tasked with looking into a series of murders, but her inquiry revealed a broken LTC system
By Matt Gurney - Published on Jun 06, 2020
Justice Eileen E. Gillese, commissioner of the public inquiry into the safety and security of residents in LTC, delivers her report in Woodstock on July 31, 2019. (Geoff Robins/CP)



This is the fourth and final instalment in a series looking at what was known about the state of long-term care in Ontario prior to the pandemic. Read Part 3 here.

The COVID-19 pandemic has ravaged Ontario’s long-term-care homes. The majority of the province’s pandemic deaths have occurred in these institutions, where conditions became so dire the province was forced to call on the Canadian Armed Forces for desperately needed help. Those soldiers, in turn, observed conditions so appalling that a report was transmitted back to National Defence headquarters in Ottawa — a report so bleak that Premier Doug Ford has said reading it was the hardest moment of his time in office. The provincial government has pledged an independent commission to look into the LTC system; the provincial ombudsman has begun its own investigation. But Ontario’s LTC system has been extensively studied for years. The problems that made the pandemic so devastating had not been unknown. This week, TVO.org will catalogue just a few of the reports, papers, and other warnings regarding the state of our LTC system that were issued before the pandemic — and that we could have acted on. Today: Justice Eileen E. Gillese’s final report from the public inquiry into long-term-care homes.

Readers who have read the earlier instalments of this series will notice something different about this one right away. The earlier instalments were interviews with people who’d participated in drafting reports about the province’s long-term-care system and its systemic challenges. An interview was impossible in this case; as a sitting judge, Justice Eileen E. Gillese was not able to agree to an interview (though she declined very graciously).

But, as useful as an interview might have been, her work speaks for itself. And it hung over every interview conducted for this series: it was referenced, directly or implicitly, by everyone I spoke to.

Gillese’s report, released in July 2019, was ordered in response to the horrifying crimes committed by Elizabeth Wettlaufer, a nurse who confessed to murdering eight patients in her care in various LTC facilities in Ontario. Between 2007 and 2016, Wettlaufer — who was written up on many occasions for serious workplace failures — murdered eight patients by injecting them with fatal doses of insulin. (A number of other patients survived similar incidents; these were deemed by the court to be attempted murders and aggravated assaults.) Gillese’s inquest was intended to look specifically at Wettlaufer’s crime, but the mandate was expanded to include a broader consideration of Ontario’s LTC system.

The portions of the report that focus on Wettlaufer’s crimes are beyond the scope of this series and will not be addressed here, beyond this personal observation: there is something particularly chilling about reading about those terrible crimes in the calm and collected words of a public inquiry — the detached tone somehow amplifies the horror.

But there is still plenty of material about the system itself. And none of it is surprising.

The report is 1,500 pages long and spread across four volumes. But it wastes no time in establishing that, in order to understand how Wettlaufer was able to operate, you have to understand the state of the long-term-care system. Her murders, for example, were made vastly easier by chronically low staffing levels in the system — at night, when staffing was at a minimal level, Wettlaufer had virtual free rein to access supplies of insulin and administer fatal doses.

Gillese notes very early in the report that, “although the long-term care system is strained, it is not broken. The regulatory regime that governs the system, together with those who work in it, provide a solid foundation on which to address the systemic issues identified in this inquiry.” She later adds, “There is real significance to my finding that the long-term care system is not broken. Ontario has no need to jettison the existing regulatory system and start over. Instead, we need to identify and acknowledge the strengths of the existing system and build on them.” The failures she did find, she writes, could be addressed via her report’s recommendations. (Anyone who has read such reports will be familiar with the particularly dry tone of such recommendations. This one is an excellent example: “identify, recognize, and share best practices leading to excellence in the provision of care in LTC homes.” Edgy!)

The most useful part of the report is Chapter 4 of the second volume, in which Gillese provides a concise summary of the staffing structure of a long-term-care facility. There are administration and management jobs, of course — which matter but aren’t most relevant to the actual hands-on care. There are personal-support workers, whose responsibilities, Gillese notes, are not actually defined in any legislation but who play vital non-medical roles: “[PSWs] are responsible for assisting residents with all activities of daily living and personal hygiene, such as bathing, dressing, and toileting; transporting residents to and/or assisting residents in getting to and from the dining room and other places within the home; assisting residents with their meals; and charting all non-nursing and non-medical aspects of the residents’ activities of daily living.”

But much of the attention in the section is (understandably, given the circumstances) focused on nursing. LTC homes are “obliged to ensure that 24-hour nursing service was available,” she notes, but that isn’t further defined — the LTC home’s management determines the appropriate level. The lack of specific constraints is somewhat offset by legislative requirements that facilities maintain “a written staffing plan that provides for a staffing mix consistent with the residents’ assessed care and safety needs; promotes continuity of care; includes a back-up plan to ensure nursing coverage when staff cannot come to work; and is evaluated and updated at least annually.”

But this is a struggle, the inquiry found. Overnight shifts, in particular, are a challenge (this was key to Wettlaufer’s crimes). LTC homes, in effect, rely on temp services to maintain staffing levels, especially overnight.

The relatively low societal appreciation for long-term care is a factor, Gillese found. So is strong competition from hospitals: nurses have options when looking for work. “When the heavy workload in LTC is considered in combination with these other matters,” Gillese writes, “it is easy to understand why homes have difficulty recruiting and retaining nurses.”

The report also notes that, even as facilities struggle to maintain sufficient staff, they are dealing with increasingly complicated patient-care needs: “LTC homes have always cared for residents needing a level of support beyond what is possible at home, but there has been a sharp increase in the proportion of residents with high acuity in recent years.” A greater emphasis on home care and aging in place, though defensible on its own merits, has created a problem for LTC homes: residents now “enter LTC homes at a later stage of their cognitive and physical impairment, when their health is likely to be unstable, they are more physically frail, and their care needs are higher.”

Meanwhile, even as the care becomes more urgent, there’s less time available to deliver it, due to paperwork requirements imposed by the legislation. “In recent years,” the inquiry found, “nursing staff (as well as personal support workers) in LTC homes have been tasked with increasing documentation responsibilities … Although the rationale for the increased documentation is compelling, these extra responsibilities have increased the workload of nurses in LTC homes. Many of the nurses who testified said that, to get their charting done, they routinely have to stay after their shifts end (for which they are not paid).”

Again, this is only a small part of the inquiry’s sections on the LTC system, which themselves are a small part of the overall report. But these are precisely the issues that were raised, over and over, in my previous three interviews: low staffing, issues with morale and retention, highly complicated resident-care needs, and crushing paperwork burdens. And this was all before the pandemic.

The path forward is clear enough: more budget to permit more people to work in modernized facilities. If this had been done years ago, workplace safety and morale, not to mention patient care, would have improved, and we would have produced a more resilient system — one better able to withstand the impact of COVID-19. (The issue of PPE, as noted in Part 3 of this series, is separate, and will require specific corrective action; among the major challenges our LTCs have struggled with during the pandemic, it was arguably the only one that was not well-understood long in advance.)

But this path will mean more money from a province that had been facing a constrained fiscal situation even before the pandemic’s devastating impact on our economy and, along with it, government revenues. It’s very easy to make the case for more spending on a better, bigger, and more resilient long-term-care system in Ontario. It’s just as easy to imagine it never happening.

After all, it didn’t before. And we were warned. Perhaps the pandemic has finally knocked us out of our complacency. Let’s hope so. Whether from a later wave of this pandemic, or the next ones, lives depend on it.

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