The president of a Woodstock nursing home called the company's lawyer and a public relations firm, not the Ontario Ministry of Health and Long-Term Care, when he learned then nurse Elizabeth Wettlaufer had confessed to killing seven residents, a public inquiry heard Tuesday morning.
“I asked him specifically why he didn’t report to the ministry. He said he didn’t know what to do,” Karen Simpson, the former director of long-term care home inspections at the ministry, testified at the Elgin County courthouse in St. Thomas.
"He said that he had received this information — it was the most shocking information that he had ever received and he didn't know how to move forward."
That conversation happened two days after Jim Lavelle, president of Caressant Care Nursing and Retirement Homes, found out from police that Wettlaufer had confessed to the killings.
Two days later, he called the Ontario Long Term Care Association, an umbrella group for nursing homes.
"That was something that they should have reported right away, which is why I raised it with him," Simpson said.
She learned of Wettlaufer's confession after getting an email from the chief executive director of the association.
“You may want to sit down for this …” the email begins, before outlining Wettlaufer’s confession.
An email sent by the head of the Ontario Long Term Care Association to other senior staff and forwarded minutes later to the Ministry of Health and Long-Term care. (Supplied)
Wettlaufer checked herself into a psychiatric hospital, and told doctors she had killed eight people and tried to harm six others while working in Ontario nursing homes and home care from 2007 to 2016.
Ontario government inspectors were dispatched to the three nursing homes where Wettlaufer worked immediately after the ministry was told of the killings, Simpson told the inquiry on Monday.
'Didn't understand obligations'
Lavelle's failure to report Wettlaufer's actions was the last of a large number of reports that Caressant Care staff and administrators should have given to the ministry but didn't.
When Health Ministry inspectors reviewed files spanning Wettlaufer's career, after her crimes became public, they found 41 medication errors that should have been reported to the ministry. Such reports can trigger inspections that could lead to orders to comply with legislation, Simpson said.
In October 2007, four months after Wettlaufer began working at the Woodstock home, one resident, Clotilde Adriano, 87, was rushed to hospital after an insulin overdose.
That medication error, made by Wettlaufer, should have been reported to the ministry but wasn't.
Wettlaufer was eventually charged with aggravated assault.
3 homes under scrutiny
Three homes where Wettlaufer worked and killed or harmed patients were the focus of provincial probes after she confessed, the inquiry heard Monday:
- Meadow Park in London.
- Caressant Care in Woodstock.
- Telfer Place in Paris.
Investigations at the homes began in October 2016, the same month Wettlaufer confessed.
Caressant Care, where Wettlaufer worked for seven years and killed seven of her eight victims, was told to stop admitting residents while it dealt with problems identified in those inspections, Simpson testified.
The investigations found many unreported incidents that should have been reported.
The reports were supposed to be made under rules in the Long Term Care Homes Act. The legislation, which came into force in 2010, put strict reporting obligations on facilities such as Caressant Care and gave provincial inspectors more powers.
But the new system also relied heavily on self-reporting of problems that would trigger inspections.
Eventually, Caressant Care was ordered to hire an outside company to help it manage the home. That order remains in place today.
Simpson testified there are many safeguards to protect residents, and that Wettlaufer's crimes were not detected by anyone, from residents to staff to inspectors.
"This has had such an effect on so many people," she said. "If there are improvements [to inspections] we can make, we will absolutely look at that. We need to hear that."
Simpson will be cross-examined on Tuesday. Later this week, the inquiry will hear from investigators who went into the nursing homes after Wettlaufer's confession.
On June 26, 2017, Wettlaufer was sentenced to eight concurrent life terms in prison with no possibility of parole for 25 years.
The inquiry into the safety and security of residents in long-term care is expected to last until September.
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