Six things we've learned so far at the Wettlaufer inquiry

After the first phase of the long-term care inquiry in Ontario, we circle back to see what we've learned from the testimony. 

The Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System was called after Elizabeth Wettlaufer was sentenced to eight concurrent life terms in prison. 

The inquiry is currently on break until July 16 and is expected to wrap up in September.

In September 2016, Wettlaufer, a registered nurse who worked in nursing homes and in people's homes, confessed to injecting people with large amounts of insulin between 2007 and 2016, killing eight and harming six. 

The inquiry is examining how Wettlaufer's crimes went undetected for so long and is looking at systemic problems with long-term care in Ontario. Here's what we've learned so far: 

1. It's difficult to recruit and retain nurses

Work in long-term care is not glamorous and it doesn't pay as well as work in hospitals, the inquiry has heard. 

Each of the managers of nursing homes testifying at the inquiry said it was very difficult to recruit nurses and to keep them. Nurses tended to want to work in hospitals, where there was better pay and smaller staff-to-patient ratios, officials said. 

That shortage meant managers were reluctant to get rid of a nurse, because a replacement was difficult to find. 

The shortage is even more acute in rural communities, where many don't want to work, or don't want to commute. And it's meant some nursing homes rely on temp agencies to supply nurses if one of their own calls in sick or isn't available. 

2. Red flags were ignored 

The system set up to protect patients instead allowed Wettlaufer to go on killing for almost a decade, without anyone noticing. 

Wettlaufer was fired from her first job out of nursing school in 1995 at Geraldton District Hospital. 

While there, she stole narcotics and overdosed during a shift. But her union, the Ontario Nurses Association, intervened, and her firing was noted as a voluntary resignation. 

Again, her union intervened. Wettlaufer also got a $2,000 settlement, her employment record was sealed and she got a letter of reference. There was no way for future employers to know what problems there were with her. 

At her next job, at Meadow Park in London, Ont., she quit the same day a bunch of narcotics went missing, and police suspected that she'd stolen the drugs. But no one reported Wettlaufer to the College of Nurses of Ontario, the profession's regulatory body, which could have investigated her. 

Also, the Ontario coroner was twice told deaths at the nursing homes where Wettlaufer worked were unexpected or sudden. But autopsies were not performed. One coroner told a nurse, "no death in a nursing home is unexpected." 

3. Long-term care patients are sicker and frailer

Those who end up in long-term care are frailer, sicker and need much more care than they used to. 

Ontario's back-logged health care system means that sometimes, hospitals discharge people who were previously homeless, have multiple diagnoses or are severely overweight, into long-term care homes. 

That puts pressure on officials who are trying to care for sicker patients but who are also trying to deal with residents who have very different needs. Some are addicted to alcohol while others are elderly and have dementia, for example. 

4. Nurse-to-patient ratios are very high

Long-term care homes pay for nurses out of a budget that is dictated based on the number of residents and the acuity of the residents. But each manager who has testified at the public inquiry has said they could use more staff — there's just not enough money. 

At one care home, Caressant Care, there was one nurse for 99 residents on the night shift.

The high ratio also means nurses often stay after the end of their shifts for an hour or two to complete required paperwork, or do the paperwork during their shifts when they'd rather be spending time with residents, the inquiry has heard.

And it prevents nurses from doing suggested, but not required, double-checks.

For example, nurses at one home were to double-check each other's insulin administration where possible. The high workload made it impossible to do those double checks — but it gave Wettlaufer free reign over administration of the potentially lethal drug, the inquiry heard.

5. Regulations can be a hindrance to patient care

Because funding is based partly on patient acuity, it means nurses have a lot of paperwork to fill out to get that funding. And it means they spend less time with residents than they'd like to. 

There are also some regulations that are misunderstood by some nurses and managers — such as when a nurse is supposed to be reported to the College of Nurses. 

At Lifeguard HomeCare, a temp agency for nurses, Wettlaufer confessed to having a drug and alcohol dependency and that she was drinking. But her employers didn't think they should report her because they didn't witness her being intoxicated on the job and because she had already quit. 

Wettlaufer's status with the Ontario College of Nurses was changed to "not entitled to practice" after she was arrested and while the College conducted its own investigation. A month after Wettlaufer was sentenced, the College proceeded with a disciplinary hearing to officially revoke her license. 

And the Ontario Nurses Association was bound by labour law regulations to defend Wettlaufer when she was suspended or fired, without doing an investigation into the circumstances surrounding the errors. 

6. Some things haven't changed — yet

It's been suggested at the inquiry that at least two systemic failures still exist, two years after Wettlaufer confessed to her crimes. 

The College of Nurses still doesn't note on its website if it's investigating a nurse. It also doesn't list if a nurse's employment history includes being fired. 

An executive with a home health care agency testified last week that it had hired a nurse who appeared to be in good standing with the college only to find out six months later there was an active investigation into the nurse's actions. Her ability to enter people's homes was eventually restricted by the College, but not before she worked in people's homes for half a year. 

That same agency, St. Elizabeth Health Care, still doesn't call references, relying only on an online portal to find out about a potential employee's past employment. 

An executive testified nothing more could be gained from a phone call. 

But lawyers have suggested to St. Elizabeth and other long-term care providers at the inquiry that calling all of a potential employee's former supervisors, not just the ones provided, could shed important light onto the kind of employee they would be getting, and potential problems that might exist.