Coroner maintains he didn't miss anything in deaths of 2 of Wettlaufer's victims

The local coroner responsible for reviewing the deaths of two of Elizabeth Wettlaufer's victims told the inquiry into the safety and security of residents in the long-term care homes system that he didn't miss anything in his investigations.

Silcox was the first person Wettlaufer killed.

The public inquiry being held at the Elgin County courthouse in St. Thomas, Ont., is looking into how Wettlaufer was able to get away with killing eight people and harming six others while working as a nurse in long-term care homes in southwestern Ontario.

Both Silcox and Pickering were residents of Caressant Care nursing home in Woodstock, Ont., and both died after Wettlaufer injected them with massive amounts of insulin. 

Neither was flagged for an autopsy by George. 

"Looking at it now, do you think you should have done an autopsy on Mr. Silcox?" the coroner was asked by lawyer Rebecca Jones. 

"No," George replied. 

"Looking back, do you think you missed anything?" she asked. 

"No," George replied. 

Silcox's death was investigated by George because the elderly man had fallen prior to his death. It was Wettlaufer who filled out his death record and called it an "accident" and "sudden and unexpected." 

Upon reviewing medical files, George declined to perform an autopsy. 

He had a similar response to the death of Pickering, who was admitted to hospital with severe low blood sugar. 

That information was reported to George by someone from the provincewide central dispatch service. But while he considered the possibility that the low blood sugar was a result of a medication error made in the nursing home, George again dismissed the possibility that he missed anything. 

Even looking back, knowing about Wettlaufer's crimes, George said he doesn't think he should have investigated Pickering's death further. 

"Her death was foreseeable and it was expected," he told the lawyer for the inquiry, because Pickering was palliative and had had a stroke. 

Notes not kept, family not happy

But George's recollections are based on his memory and review of medical charts, not on notes he kept at the time of the deaths, the inquiry heard. 

That's because while he took notes at the time, he didn't keep them, George testified. 

He knew that was a requirement, but he just didn't, he said. He said he now keeps his notes. 

A summary of Silcox's death in a medical chart states that the elderly man's family was consulted after he died and "had no further concerns." 

But Silcox's daughter is expected to testify that no one ever spoke to her or other family members about her father's death. 

In fact, the daughter asked if an autopsy would be performed but Wettlaufer told her it was unlikely, according to inquiry  documents. Wettlaufer suggested the daughter call the coroner in four to six weeks. 

When she did call the coroner, he was dismissive and felt her concerns were unwarranted because her father was elderly. 

George testified it was his usual practice to speak to family members, but he has no notes to indicate whether or not he did so in the Silcox case. 

He rejected the suggestion that he was rude to Silcox's daughter. 

"I would never have been dismissive. I have great respect for the dead and their families," George testified.

He will be cross-examined by a lawyer who represents the loved ones of some of Wettlaufer's victims this afternoon. 

Coroners rely on doctors, nurses

On Tuesday, the inquiry heard that Ontario's coroners rely on nurses and doctors to report their own possible mistakes or negligence when a patient dies.

When doctors or nurses fill out a document after a patient's death in long-term care, they're asked if they suspect abuse or neglect, or if the death was "sudden or unexpected," which would trigger a coroner to perform a death investigation. 

That investigation could lead to an autopsy, Huyer said. 

But if doctors and nurses don't report their own abuse, it's nearly impossible for coroners to know about suspicious deaths. 

"I do not believe that it is possible to create an effective screening process within the long-term care sector to effectively ensure the detection of homicidal actions of a person who is carefully taking steps to conceal their actions," Huyer wrote in his affidavit for the inquiry. 

"The public give us potentially more credit than we are due for being able to identify something like a hidden or concealed or secret homicide where there isn't information brought forward," he testified. 

Wettlaufer killed eight people and tried to kill another six patients while working as a nurse tending to the elderly in home care and at nursing homes for almost a decade. 

She was never caught. In 2016, when she was being asked to work with children, she checked herself into a psychiatric facility and confessed to her crimes.