Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System
Read the report by the Honourable Eileen E. Gillese, Commissioner of the Long-Term Care Homes Public Inquiry.
About the report
In June 2017, a nurse was convicted of eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault. She committed the offences between 2007 and 2016 in the course of her work as a registered nurse in long-term care homes. In every case, the victims were intentionally injected with an overdose of insulin. The offender was sentenced to life in prison with no chance of parole for 25 years.
On August 1, 2017, a public inquiry was called to determine the events and contributing factors leading to the offences and make recommendations to avoid similar tragedies within the long-term care system.
The two-year inquiry concluded with three principal findings and several recommendations.
Read the full report
Volume 1 – Executive Summary and Consolidated Recommendations (860KB PDF)
Volume 2 – A Systemic Inquiry into the Offences (7.4MB PDF)
Volume 3 – A Strategy for Safety (1.9MB PDF)
Volume 4 – The Inquiry Process (5.0MB PDF)
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