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cover inquiryvol3Report by the Honourable Eileen E. Gillese, Commissioner

"The Long-Term Care Homes Public Inquiry was established on August 1, 2017, by Order in Council following Elizabeth Wettlaufer’s conviction of eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault; offences she committed while working as a registered nurse in Long-Term Care Homes.

The Inquiry’s mandate is to inquire into the events which led to the offences committed by Elizabeth Wettlaufer. Additionally, the Inquiry is directed to inquire into the circumstances and contributing factors allowing these events to occur, including the effect, if any, of relevant policies, procedures, practices and accountability and oversight mechanisms. The Inquiry is also directed to inquire into other relevant matters that the Commissioner considers necessary to avoid similar tragedies."

This is Volume 3 ("A Strategy for Safety") of the 4-part report. The Commissioner’s final report and Recommendations can all be found here

Volume 3:
"Based on the evidence I heard in the public hearings, it is my view that systemic failings in the long-term care (LTC) system – not individual ones – created the circumstances that allowed Wettlaufer to commit the Offences. In this volume of the Report, I describe the systemic vulnerabilities identified through the Inquiry processes and propose systemic responses that must be taken if we are to avoid similar tragedies in the future. These responses are designed to prevent, deter, and detect wrongdoing of the sort that Wettlaufer, a healthcare serial killer (HCSK), committed. This chapter is devoted to strategies whose goal is prevention. Later chapters in this volume are directed at the strategies for deterrence and detection."

Source: The Long Term Care Homes Public Inquiry


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