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Voice of Family Members Critical in Wettlaufer Inquiry: Koster

The Advocate Files: Legal Supplier | Nursing Home Abuse


Voice of Family Members Critical in Wettlaufer Inquiry: Koster

TORONTO — A surviving victim, relatives of murdered seniors, and advocacy and health-care groups are among 17 groups and entities granted permission to take part in a public inquiry sparked by nurse Elizabeth Wettlaufer, who is serving life for killing eight elderly long-term-care residents in Ontario.

In her decision released Thursday, Commissioner Eileen Gillese said survivor Beverly Bertram along with victims’ family members and close friends — organized into three separate groups — will have the right to call and question witnesses.

“It is self-evident that each of these applicants has a substantial and direct interest in the subject matter of the inquiry,” Gillese wrote in her decision. “Each has suffered, and indeed continues to suffer, as a direct result of the offences.”

In an interview, workplace violence and elder abuse specialist Denise Koster says family members’ involvement in the inquiry is invaluable by using their strength to influence a “less-than-perfect” system.

“Family members can provide a unique perspective and human side to the inquiry so that their loved one is not just known as #1 or #5 murder victim, but as a human being who was lost in the most tragic of circumstances when they were at their most vulnerable,” she says. “The families now can have a voice in what should have or could have happened if things were dealt with differently.”

Resident care and health and safety concerns require thorough, unbiased investigations resulting in recommendations for improvement says Koster, principal of Koster Consulting & Associates.

“More accountability must be placed on the entire stakeholder group to communicate and work together for the greater good of resident care rather than spending time determining who is at fault for an issue, therefore losing sight of the ultimate resident safety goal,” she says.

Given their direct knowledge of the offences and surrounding circumstances, their participation will “further the conduct” of the hearings and contribute to their openness and fairness, Gillese said. To facilitate participation, the commissioner also recommended the government provide them financial aid.

The Ontario government set up the Long-Term Care Homes Public Inquiry in August after Wettlaufer, 50, was convicted of eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault. Wettlaufer had pleaded guilty in June and was jailed for life without parole eligibility for 25 years.

The province, the regulatory body for nurses, and the facilities where Wettlaufer killed her victims all have a strong and direct interest in the proceedings and were also granted full standing, Gillese decided. Most of the killings took place at Caressant Care in Woodstock and one in Meadow Park in London.

Also recognized were several organizations that work in the system of Ontario’s long-term-care homes. Among them are the Ontario Long Term Care Association, the largest group of long-term-care home providers in Canada; the non-profit advocacy group AdvantAge Ontario; and the Ontario Association of Residents Councils.

Other organizations representing doctors, nurses, registered practical nurses and other clinicians who work in nursing homes will also be allowed to participate fully.

“Although these organizations were not directly involved with Elizabeth Wettlaufer or the events in question, each offers a unique, representative perspective,” Gillese wrote. “Each has played, and continues to play, an active role in shaping the policies, procedures and practices.”

Three of those entities should receive government funding to defray their legal costs, Gillese ruled.

In all, 50 applicants applied for standing. Gillese rejected requests from seven individuals with friends or relatives in nursing homes, and another 10 who have worked in the facilities. Those people are either not closely enough connected to what happened or will see their viewpoints reflected by those who were granted standing, Gillese said, adding they can still make written submissions.

Wettlaufer injected her victims with insulin at three long-term care facilities and a private home between 2007 and 2016. She was fired twice during her career — the first time in 1995 — but kept her licence as a registered nurse. She confessed to police to feeling a “red surge” that made her think God was directing her murderous actions.

Bertram, who was 68 at the time, has previously described the pain she felt after Wettlaufer gave her a massive overdose of insulin in a failed effort to kill her.

“I knew I was dying,” Bertram said. “I was doubled over in pain.”

Gillese, a justice of the Ontario Court of Appeal, is expected to begin hearing from witnesses in June and report by July 31, 2019.

Koster says long-term care is a complex system that requires strong partnership not only with professional stakeholders but also with resident families and friends.

“This collaboration needs to be respectful and transparent focusing on the individual needs of the residents as opposed to individual, organizational or ministry egos,” she says.

The ultimate hope, Koster says, is that the inquiry will have a major impact on policy, but for that to happen, funding dollars must be allocated by the government for more staff, adequate training and quality improvement plans.

“If an outcome is a new model of long-term care, it needs to be developed with a sustainability plan, which is internally and externally monitored and revised on an annual basis to reflect the changing needs of present and future residents,” she says.


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Denise Koster 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. Learn more about Koster Consulting & Associates.

Discover more about Elder Abuse and Nursing Home Negligence Consultant, Denise Koster.


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