Vol. 11, #13.5 – February 29, 2019 – ALLAN GOLD’S BLOG
Tenth (extra) blog post of series on Elder Law for seniors and their families, particularly spouses, adult children, caregivers, etc.
Today’s Topic : Health Care Killers – Part – 2
A. OPENING
I am continuing on with the topic of health care killers. The murders that they commit are hugely grotesque. This is because these murderers are the antithesis of people typically on the medical team or on staff rendering personal care in a seniors’ residence. And it’s also due to the great harm which is being inflicted by them. Today, I will recount a story that will hit close to home as this notorious killer is a home-grown Canadian. So let’s proceed in our survey of the worst of the worst in our health system.
B. HORRIFIC REAL- LIFE EXAMPLES: Elizabeth Tracy Mae Wettlaufer
I will hereafter write about the case of Elizabeth Tracy Mae Wettlaufer, providing some biographical-case notes, issues & lessons to be gleaned, etc. therefrom. I graded it 
or or or . Of course, I’m interested in knowing if you agree with this ranking.
Elizabeth Tracy Mae Wettlaufer. If we established a Caregiver Hall of Infamy, she would be a big name exhibit. You see, this former registered nurse was the first convicted serial killer in the history of Canada’s health-care system. It is noteworthy that the accused confessed and provided a lot of information during the interrogation stage. Wettlaufer pleaded guilty to eight counts of first-degree murder, (killing eight seniors with fatal doses of insulin), four counts of attempted murder and two counts of aggravated assault. Convicted of murder in Canada, she was sentenced on June 26, 2017, to a life term with no chance for parole for 25 years. Justice Thomas said. “She was far from an angel of mercy. Rather, she was a shadow of death that passed over during the night shifts that she supervised,…” As a Canadian, I ask: “How could such a person have walked the same streets as us?”
Biographical-Case Notes: Biographical-case notes: Wettlaufer was born June 10, 1967 to Doug and Hazel and raised on the outskirts of Woodstock, Ontario, Canada. She grew up in a staunchly Baptist household. She attended Huron Park Secondary School, where she was a member of both the band and choir. She was on her school’s field hockey team in 1982. She graduated in the mid-1980s. In her high school yearbook, Wettlaufer said that she hoped to study drama in university. She went on to earn a bachelor’s degree in religious education from London Baptist Bible College, since renamed Heritage Baptist College. Afterwards, she became a registered nurse in Ontario. Wettlaufer often worked as the nurse in charge on the night shift at long-term care homes in the southern Ontario cities of Woodstock, Paris and London. It is noteworthy that in the News & Announcements of July 25, 2017, the College of Nurses of Ontario reported that at a discipline hearing, Wettlaufer’s nursing registration was revoked.
In an article written after Wettlaufer admitted to killing eight patients under her care, titled, “Health-care killers ‘statistically rare’ but difficult to spot, “Posted: Jun 03, 2017 5:00 AM ET | Last Updated: June 3, 2017, Meagan Fitzpatrick/CBC News provided a few opinions of experts on topic. Michael Arntfield, Assistant Professor at University of Western Ontario (Western University): He is the author of a book on serial killers titled “Murder in Plain English. He believes that health-care workers who kill are “statistically rare,” but when they offend, they tend to kill a lot of people before they’re stopped. He stated: “It is not entirely surprising that in Canada, our first known health-care serial killer is so prolific…Health-care serial killers frequently have the highest body count of all serial killers because they have daily access to victims.” (And these kinds of killers can often go undetected because they’re in a field dealing with life and death.). He explains the motivation of these killers as looking to exert power they don’t have in their own lives. And as to the choice of victims, he says that they select people who “essentially just annoy them.” He said: “What we see in cases like Wettlaufer’s is that it reveals to us just … what a blind spot in the system health care could be for a motivated offender who wants to exploit that access to vulnerable people,…” By using the phrase, ‘Canary in a coal mine’, he emphasizes the ‘needle in the haystack’ task imposed on the health network, to address the potential dangers posed by these offenders.
Beatrice Crofts Yorker, Researcher at California State University (Los Angeles): She has studied serial killers in the health-care field. She says “She (Wettlaufer) fits the long-term care nursing home profile, which is power, control and an extra-heavy workload — feeling a little sadistic toward the patients.” Like Arntfield, she says nursing homes are ideal environments for serial killers: She explains that offenders at these sites, have constant access to potential victims, legal access to drugs, there are often no witnesses and the deaths may not be considered suspicious, given the patients are ill and elderly, meaning autopsies are unlikely. Although serial killers in health-care settings can be hard to catch and hard to prosecute, she is upbeat, adding:: “There are a lot of safeguards in place to deter people,”…”It’s not nearly as easy as it used to be to get away with this.” But, she cautions that the problem remains, especially since the misuse of medication isn’t always the killing tool. (Source: https://www.cbc.ca/news/canada/wettlaufer-health-care-killers-1.4143174)
A very troubling side note to this horrific story is that this killing spree could have been stopped much earlier than it actually ended. You see, there were many missed chances previously. It was half bad when people sometimes had suspicions, but did nothing. However, it’s double trouble when Wettlaufer spoke to others about her problems, even reaching out for help on occasion, but these people also didn’t do anything. Incredulous? Please be informed: (a) That apparently, on being told that she had a hand in the deaths of patients, a pastor prayed over Elizabeth Wettlaufer and told her not to kill again; (b) That a lawyer advised the registered nurse to take her murderous secrets to her grave; (c) That a Narcotics Anonymous sponsor dismissed her insinuations of harming seniors as the talk of a”pathological liar”; (d) That an ex-boyfriend attributed her confessions of killing nursing home patients to a “psychiatric episode.” (Source: https://www.cbc.ca/news/canada/toronto/wettlaufer-pastor-killings-1.4144693) …
Postscript: After this horrendous case played out, there were so many questions and the desire to do something in order to prevent future health killings. That’s why, on August 1, 2017, by Order in Council, the Ontario government established “The Long-Term Care Homes Public Inquiry” Amongst its mission goals, the inquiry was to examine Elizabeth Wettlaufer’s conduct while working as a registered nurse in Long-Term care facilities. The chief coroner of the province testified thereat. (Source: https://www.theglobeandmail.com/news/national/ex-nurse-serial-killer-wettlaufer-prison/article35460700/; https://www.thestar.com › News › Canada; https://www.thecanadianencyclopedia.ca/en/article/elizabeth-wettlaufer-case; https://en.wikipedia.org/wiki/Elizabeth_Wettlaufer ; https://www.cbc.ca/news2/interactives/sh/…/elizabeth-wettlaufer-nurse-senior-deaths/; https://www.ctvnews.ca/…/what-we-know-about-elizabeth-mae-wettlaufer-the-nurse-char; https://www.ctvnews.ca/…/wettlaufer-murders-difficult-to-detect-expert-tells-public-inqu… https://www.bbc.com/news/world-us-canada-44377735;https://www.pressreader.com/canada/toronto-star/20161029/281479275964918;
Questions at Issue & Lessons to be gleaned:
In my perspective, they are as follows.
1. Like in the Poggiali case, the first question at issue is: “Whether or not, Wettlaufer was fit and able during the nine-year killing spree, to be licensed as a nurse (and/or continue to be licensed to practice) and further to be employed in a health establishment?” My answer is “No, but in order to explain, I’ll break the question into several sub-questions, which are:
1.1 The first sub-question is “Through these nine years, did she suffer from mental illness?” I start my response by saying that as per the Mayo Clinic, the phrase, “mental illness” refers to a wide range of mental health conditions — disorders that affect mood, thinking and behavior.” Next, I assert that, in the facts, it was found that Wettlaufer was dealing with mental health issues that included “suicidal tendencies and substance abuse.” It’s also noteworthy that she was in rehabilitation (rehab). “Furthermore, it was reported, “In a taped confession in October 2016 to police, which was played in court, Wettlaufer offered various explanations for her actions. At one point, she said she believed that either God or the devil wanted her to kill these people. At other points, she said that she “felt an uncontrollable ‘red surge’ before killing elderly patients.” Enough said, I think that you’ll agree with me when I conclude that she was unwell mentally speaking.
1.2 The second sub-question is “At this time, whether she was mentally fit to practice as a nurse and be employed as a care giver?” To this, I say that given what she has done, it’s self-evident that she couldn’t have been mentally sound and since she was acting abnormally, she was wholly unfit to be licensed or be hired and be on the job in a care institution; 1.3 “In third spot, my sub-questions are: “Whether educators, the licensing authority and/or the employers did enough in order to discover that she was unfit?” and also, “Were there in place the means for them to do so? “My answer is “No.” Apparently, some family, friends had said: “Behind that normal person (Wettlaufer) is a monster’. They were right. But in this case, those mandated to teach, license, hire and supervise nurses, failed dismally in their function. Indeed, there is plenty of blame to spread around. In this regard, I submit:
1.3.1 That the first check should have been during Wettlaufer’s education. (N.B. I don’t believe that she suddenly and deliberately started to attack at least eight people in her care. Instead, I urge that the seeds were there long beforehand.) I contend that it’s probable that in nursing school, she had some psychological problems and then and there, she should have been removed from the program. In my opinion, the failure was not paying close attention to students and their behavior.
1.3.2 That in my belief, it’s probable that Wettlaufer should not have been licensed in the first place. Of course, the Ontario’s nurse licensing authority needed to find out about her mental problems at the earliest time possible. During the pre- licensing period, I suggest that if it knew what kind of shape she was in, it would have rejected her going in. And for me, it didn’t know this because it didn’t then ask, the right questions and require all of the right recommendations, reports, etc.
1.3.3 That without a doubt, once Wettlaufer received her license through to the end of the awful nine year period of killing, she was unfit and her condition likely worsened. And since she had to maintain her licensed status, it’s undeniable that her professional organization had missed many opportunities to catch her unfitness. The reason again was because it didn’t yearly ask the right questions and require all of the right recommendations, reports, etc. And perhaps, there should have been some one-on-one time to interview the candidate for yearly re-licensing.
1.3.4 That respecting the health institutions, who were Wettlaufer’s employers, I urge that they must shoulder some of the blame as well. While she certainly had to provide details of her past work history and references, it’s patently clear the message of Wettlaufer not being hireable, did not get through from former employer to new employer. And certainly, there had to be at least one interview. As a result, it’s self-evident that the interviewer failed to pick up on the candidate’s abnormality.
1.3.5 In the aftermath of the Wettlaufer case, a lawyer for a long-term care facility where one of Wettlaufer’s victims died, was quoted as saying that the Ontario nurse’s case was an anomaly. In my opinion, he was trying to rationalize the failure on the part of his client and minimize the liability thereof. He was also implying that in actuality, we have a health network, made up of people and no matter what we do, aberrations do happen and we cannot do anything about them. In effect, he is also striving to say that an incoming patient to a facility must accept this as a fact of life. I disagree.
1.3.6 For me, probably before and surely during Wettlaufer’s nine year spree, she was offending and as such, she was a seriously flawed worker, wholly unfit for the job had by her. But facility managers did not ring the bell for law enforcement. Instead, they literally and figuratively preferred to keep “their skeletons in the closet”. Let’s call it what it is …a cover up. The probable reason was that they didn’t want to call attention to what she had done and possibly open a “can of worms” by triggering complaints against management or lawsuits against the institution. So they opted to suck it up and ‘kick the can down the road’, passing the buck to someone else, thereby leaving her free to apply to another care facility and get employed and ultimately continue killing. The correct take-away from this experience is that any establishment or any person in our health network must alert law enforcement and other institutions of any suspicious happenings or behavior.
2. Again like in the Poggiali case, the questions in second place are: “Whether or not, the licensing authority (nursing professional order) fulfilled its obligations owed to the public?” and “Whether or not, the care facility -residence, fulfilled its obligations owed to its patients-residents, notably to have personnel render service, up to the right standard of care and to keep patients safe?” My answer to both is: “Probably not. “ It’s clear that they had these obligations and they didn’t satisfy them in an acceptable way. However, in their, defense, Wettlaufer was a registered nurse and was therefore presumed to be fit and proper to do the job. And to be fair, it’s true that these murders are difficult to detect. However, in any event, it’s likely that Wettlaufer’s condition worsened over time. Since management had the responsibility of staff supervision, there was a need for supervisors fulfilling their role, looking for the first hints of wrong doing, serving as red flags.
C. CLOSING
Unfortunately, there have been instances in the past when people commit crimes at work. But it’s very surprising when it happens in a health care facility. Wettlaufer fits the pattern of many health-care killers. But what distinguished this case from the others and perhaps moderates her guilt, was the fact that she came forward and confessed and she herself, put an end to the killing spree. For this, I must say to her, “Thank you for that but I still must ask: “How could you?”
To all citizens, I say: “There’s always something to do; and there’s always something to do better. With this problem, it’s really quite simple really- we need to catch these miserable people before they commit their first crime or immediately afterwards, before they escape down the rabbit hole to later emerge and repeat their criminal ways. The solution is to pay attention at what’s going on around you, and on seeing something that doesn’t look or feel right, STAND-UP & SPEAK UP for patients/residents and DO it without delay!”
D. PREVIEW OF NEXT IN THE BLOG SERIES: Health-Care Killers- Part #3 I believe that with this blog series on elder abuse, I may have got you thinking about the safety and security of the aged. Last time, I introduced the topic of killers in a hospital (chronic care facility) or a seniors’ residence; and I also cited a few cases, which perhaps raised your angst level. Today, I dealt with an awful Canadian case. Please stay tuned-there’s even more frightful stories to come. In the third part, I will continue on giving you even more horrific real- life examples. Interested? Want to be frightened out of your wits? See you next time.* 
E. NOTICE – CAUTION –DISCLAIMER The material provided herein is of a general nature, strictly for informational purposes. The interpretation and analysis is not to be misapplied to a personal situation with a particular set of facts. Under no circumstances, are the herein suggestions and tips, intended to bring a reader to the point of acting or not acting, but instead, the hope is that they are to be a cause for pause and reflection. It is specifically declared that this content is not to be a replacement of or substitution for legal or any other appropriate advice. To the contrary, for more information on these presents, related subjects or any other questions, it is the express recommendation of the author that everyone seek out and consult a qualified professional or competent adviser.
*©/TM 2015, 2016, 2017, 2018, 2019 Allan Gold, Practitioners’ Press Inc. – ALL RIGHTS RESERVED