Nursing home didn't 'paint full picture' of Wettlaufer, inquiry hears

Elizabeth Wettlaufer's employers failed to report incidents that would have triggered investigations into the nurse's practice by the profession's regulatory body, the inquiry into long-term care heard today. 

Anne Coghlan, head of the College of Nurses of Ontario, is testifying at the Wettlaufer inquiry at the Elgin County courthouse in St. Thomas, Ont. 

Wettlaufer was reported to the college, the regulatory body that governs nurses in Ontario, in 2014 by Caressant Care long-term care in Woodstock, Ont., when she was fired for making a series of medication errors and being inappropriate.  

Wettlaufer worked at Caressant Care from 2007 to 2014 and, unknown to anyone at the time, killed seven people there by injecting them with insulin overdoses. 

When long-term care facilities fire a nurse, they must report that termination to the college, along with the reasons for doing so. Those reasons are looked at by investigators, who might trigger an investigation or somehow censure the nurse. The final decision about what happens to the nurse rests with Coghlan. 

But Caressant Care management only reported a handful of incidents involving Wettlaufer. Those incidents were seen as "low risk" and didn't seem to follow a pattern.

As a result, Wettlaufer was sent a letter it hoped would jar her into better behaviour.

"She needed to be reminded of her professional accountability and the college's expectations. It was generally sloppy practice," Coghlan told the inquiry. "She was practicing on the low end of the standards of the profession and some of her practices were not up to the standards." 

Looking back, the decision about Wettlaufer's ability to practice nursing would have been different if the college received more information about other incidents at Caressant Care, Coghlan testified. 

The college should also have been told about incidents at the home where Wettlaufer made sexual comments to residents, punctured a hematoma with unsterilized scissors and moved a patient with a broken hip despite his crying out in pain, Coghlan said. 

"The college would expect to receive information that signals a pattern of abusive behaviour," she said. 

"The picture we got of the member was not the full picture. We see a member who has disregard for the care and compassion that would be required of any nurse in the care of a client." 

Wettlaufer had been disciplined for some of those incidents but they were not included on the report to the college. 

"[The incidents] paint a picture of an individual who is intentionally engaging in nursing practices that fall below the standards of the profession," Coghlan said. 

Caressant Care thought it prepared a report for the college that it thought would signal they thought Wettlaufer should be investigated, but that the college didn't do an investigation because it didn't think the reported incidents warranted one, commissioner Eileen Gillese said. 

Addiction should have been disclosed

But it wasn't just Caressant Care that didn't fully report information about Wettlaufer, the inquiry heard Wednesday. 

Almost immediately after being fired at Caressant Care, Wettlaufer got a job at Meadow Park long-term care in London, Ont.

At the time, that resignation, coupled with the disclosure about a health issue, didn't mean Meadow Park had to report Wettlaufer to the college. 

That regulation changed in August 2016.  

"Where there is a resignation and that resignation is related to incapacity, the mandatory reporting legislation should be triggered," Coghlan said. 

That new regulation would also have meant a report from Lifeguard HomeCare, a nursing temp agency where Wettlaufer worked after Meadow Park. 

There, she confessed to having a drug and alcohol dependency and that she was drinking again. But her employers didn't think they should report her because they didn't witness her being intoxicated on the job and because she'd already quit. 

Forms emailed or sent by mail

Caressant Care managers have testified that they thought they had to confine their detailing of incidents involving Wettlaufer to a five-page form provided by the College of Nurses. 

That form is to be filled out, printed, and then faxed or sent by mail to the college because "our technology system is not yet at the stage where it can be submitted online," Coghlan said. 

Other employers submit the form and add additional pages where needed, Coghlan said. 

A full list of problems with Wettlaufer, especially if they involved medication errors involving narcotics or abuse of patients, could have triggered an investigation, particularly because Wettlaufer's college file included a ruling of "incapacity" from 1995, when the nurse overdose on opioids she stole while working as a student nurse. 

Relying on nurses

Earlier, the inquiry heard that the college doesn't keep records on work history and relies on its members to self-report medical problems that could affect their ability to practise. 

The public registry of the College of Nurses doesn't list nurses' employment histories — only their current employers. 

"The obligation is on the member to report to the college current employers," Coghlan said. "If there's a change, the member is to update that information with the college and on the public register." 

Prospective employers cannot get employment history from the college, she said. The college would expect prospective employers to check references for previous jobs, she said.

Nurses are asked to self report medical issues, such as mental health problems or addiction concerns, to the college. But they are not mandated to do so, Coghlan said. 

​The inquiry into the safety and security of residents in long-term care began in June and is expected to last until September.