After two years of investigation, a Canadian inquiry has found that an eight-time nursing home murderer would have eluded detection without her self-provoked confession.

The pronouncement came Wednesday, as a commissioner reviewing Elizabeth Wettlaufer’s crimes and her ability to elude detection for a decade presented formal findings to the public.

“The evidence in this inquiry shows that nothing would have triggered an investigation into Wettlaufer or the incidents underlying the offenses,” said Commissioner Eileen E. Gillese, a justice of the Court of Appeal for Ontario. “This finding is significant because it tells us that to prevent similar tragedies in the future, we cannot continue to do the same things in the same ways in the long-term care system.” 

Wettlaufer blamed anger over the 2007 break up of her marriage for the killing spree that started later that same year. After checking herself into a psychiatric hospital in 2016, she confessed. She ultimately pleaded guilty to the first degree murder of eight seniors, four attempted murder charges and two counts of aggravated assault.

She was sentenced to life in prison in 2017, with the government inquiry examining more than 42,000 documents and hearing from 50 or so witnesses, as reported by the Washington Post.

Wettlaufer landed job after job with glowing references, no one noting disciplinary action, fraction with suspicious co-workers going back to 1995 or that time she’d been fired for administering insulin to the wrong patient.

Insulin was Wettlaufer’s weapon of choice, and Gillese’s formal findings noted it was unlikely autopsies of any of the murder victims wouldn’t produced evidence of murder. 

To address systemic weaknesses in the nation’s long-term care system, she issued 91 recommendations, including calls to strengthen the management of medications at long-term care homes, bolster background and reference checks for prospective employees, and increase funding for nursing staff when necessary.

“This is an important step forward for long term care in Ontario,” Lisa Levin, CEO of provider organization AdvantAge Ontario said in a statement afterward. “Today’s report provides excellent recommendations and guidance that all system partners can implement together to safeguard seniors in long term care.”  

But the association argued the 1,500-page document could have gone further. It did not, for instance, question staffing shortages or include recommendations on labour relations such as the handling of grievances and discipline.