The Wettlaufer Inquiry Report: Implications for Regulators

Finding no individual misconduct, Commissioner Eileen E. Gillese’s report in the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System made 91 recommendations to prevent similar tragedies from occurring in the future (https://longtermcareinquiry.ca/en/final-report/). Most of the recommendations were directed towards the operation and oversight of long-term care homes, including their handling of access to drugs, and the Coroner’s office.

However, some of the recommendations were directed at how regulators could better address intentional harm to clients by practitioners. These recommendations included the following:

1. Regulators should use their position and influence to educate practitioners, and students becoming practitioners, about the possibility of their colleagues intentionally harming clients, something that was almost unthinkable in Ontario before Ms. Wettlaufer’s confession.
2. Regulators need to incorporate “the healthcare serial killer phenomenon” into how it investigates and screens complaints and reports about the conduct of practitioners.
3. For example, regulators need to raise awareness of mandatory reporting requirements by employers and colleagues and revise the forms used for such reports to include the following:
   1. A clear explanation of the mandatory reporting requirements including the content of the information that must be contained in the report;
   2. A declaration section by the reporter that they understand and have complied with those requirements;
   3. A request for all of the details and relevant supporting documents, a request for the disciplinary history of the practitioner, and the ability to expand the section in the form for providing details of the incident so as to encourage (and not deter) a full reporting of them; and
   4. The ability to submit such reports conveniently, such as by email.
4. Indeed, all policies and procedures of the regulator should be reviewed to take into account the possibility of intentional harm to clients.
5. The College of Nurses of Ontario was encouraged to share the research it has undertaken with other regulators on the issue of “how to prevent, deter, and detect healthcare professionals who may seek to intentionally harm those in their care.”

In respect of the last point, earlier this year representatives of the College of Nurses of Ontario (CNO) published an article on some of its learnings to date: Erin Tilley et al., “A Regulatory Response to Healthcare Serial Killing,” (2019) 10:1 Journal of Nursing Regulation 4. While the CNO found no algorithm for identifying healthcare serial killers, it did identify some warning signs “such as frequent changes in employment settings, patterns of poor conduct, access to high-risk intravenous medications, and concerns from colleagues”. The article also discussed strategies for preventing and detecting such conduct. The CNO has recently amended its public register to include more information about the work history of its registrants.