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Inquiry May End Complacency Over Health-Care Serial Killers

The Advocate Files: Legal Supplier | Nursing Home Negligence


The Long-Term Care Homes Public Inquiry into the crimes of Elizabeth Wettlaufer should shake nursing and medical professionals out of their complacency about the threat of serial killers in the health sector, says Toronto workplace violence consultant Denise Koster.

Inquiry commissioner Eileen Gillese, a justice of the Ontario Court of Appeal, recently released her mammoth final report, delivering 91 recommendations to stakeholders — including the provincial government, long-term-care facilities and nursing regulators — designed to prevent a repeat of the circumstances that led to the murders of several elderly patients.

Wettlaufer is currently serving a life sentence after pleading guilty to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault involving patients at her southwestern Ontario places of work between 2007 and 2016.

Koster, principal of Koster Consulting Associates, says she was particularly encouraged by the commissioner’s recommendations that the province establish a strategic plan to build awareness of the health-care serial-killer phenomenon and directed health regulatory bodies to include training on the subject for their members.

“The vast majority of health-care workers — and members of the general public — want to believe that Wettlaufer was a unique anomaly, but that’s not the case,” Koster says.

“Clearly stated in the report, Professor Crofts Yorker, an expert on the health-care serial killer, revealed that worldwide since 1970, 90 health-care serial killers have been found guilty of murdering at least 450 patients, and equally, if not more alarming, is that there were another 2,600 suspicious deaths linked to those convicted individuals,” she says.

“The kind of training that’s being recommended, in terms of what to look out for in serial killers, is going to help put people on alert, and ideally lead to early reporting and interventions of unusual or high-risk behaviour.”

Gillese wrote in her report that she had no doubt that Wettlaufer would not have been discovered had she “not confessed and turned herself into the police,” noting that her behaviour did nothing to raise the suspicions of managers, supervisors or colleagues.

The commissioner went on to identify several myths about the nurse’s crimes that she said “seriously distort the nature of the problem” they represent, and immediately set about debunking them.

They included the idea that the offences were mercy killings, that the pressures on the long-term-care system are bound to pass after the babyboomer generation is gone, that the threat Wettlaufer posed is gone now because she’s in jail, and that the offences only caused limited harm.

According to the report, the nurse was able to obtain pain-killing drugs for her own use, as well as insulin, which she dispensed in lethal doses to a number of patients. Still, Gillese declined to apportion individual blame to anyone but the former nurse.

“The offences were the result of systemic vulnerabilities, not the failures of any individual or organization within it,” her report reads. “Because it was systemic failings — not individual ones — that created the circumstances allowing the offences to be committed, it would be unfair of me to embark on a personal attribution of responsibility. It would also be ineffective: assigning blame to individuals will not remedy systemic problems or guard against similar tragedies.”

In addition, Gillese recommended the province make grants of between $50,000 and $200,000 available to long-term-care homes in order to boost infrastructure and staffing for the proper storage and tracking of medication.

“Cameras and extra security are physical counter-measures which can only raise an alarm, and perhaps make it more difficult for people to steal or inappropriately use drugs,” Koster says. “But at the same time, these systems will simply cause hesitation, or stop an act from happening as opposed to identifying high-risk employees and preventing the act altogether.”

To be really effective, she says these recommendations should be implemented in tandem with preventative measures to stop serial killers like Wettlaufer from thriving in the first place.

“Hiring and ongoing screening are more important for identifying people at high risk of offending,” Koster says, noting that the former nurse had a troubled career almost from the outset, including sanctions for drug theft and medication errors.

“It is important to understand that mental health issues do not equate to people committing crimes, but in her case, two months into receiving her licence, there were a number of concerning and illegal incidents and unsuccessful intervention strategies that should have raised red flags and been considered when deciding on revoking her licence completely or not lifting conditions placed on her practice,” she says.

Koster has commented before on how employers undervalue emotional intelligence as a quality in their workers, and she encourages clients to engage in threat assessments for their workplaces.

“Employees need to be educated about psychopaths and sociopaths in the workplace, and what behaviours to report so staff can be used as an early-warning radar system in order to identify and stop them,” she says. “Front-end hiring and screening is not just important for regulated staff, but for anyone working in the long-term health industry — whether it’s a food-service or maintenance employee — due to the vulnerability of the sector.”

Koster will present a session for AdvantAge Ontario on the impact of the inquiry for workplace investigators. For more information, click here.


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Denise Koster provides consulting services and expert witness reports and testimony in elder abuse and nursing home negligence cases. She also provides management and labour groups with investigation services, practical education, intensive training and consultation on workplace violence, harassment and other HR issues pertaining to safe and comfortable workplaces. Additionally, as a Certified Threat Manager (CTM) and Certified Workplace Violence and Threat Specialist (WVTS), Denise provides workplaces with customized threat assessment and management plans.

Discover more about Toronto elder abuse consultant Denise Koster.


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