Following the murders, an inquiry was launched to investigate the safety and security of residents in long-term care.

Justice Eileen Gillese, Commissioner of the Long-Term Care Homes Public Inquiry released her report with 91 recommendations to avoid further tragedies like those committed by the former nurse.

Gillese’s report finds that if Wettlaufer hadn’t confessed, her crimes would not have been detected and that her “offences were the result of systemic vulnerabilities, and, therefore, no findings of individual misconduct are warranted.”

also states that it would be very unfair to make findings of individual misconduct, particularly toward Wettlaufer, and ignore the systemic vulnerabilities that are obvious and apparent.

“If you point your finger at someone, what happens is everyone else can give a big sigh of relief and say, ‘ah, there’s the problem,” Gillese said in a press conference on July 31, 2019. “Assigning blame to individuals does not remedy systemic deficiencies or problems.”

Wettlaufer left her position at Caressant Care nursing home in Woodstock, Ontario in 2016, checking herself into a psychiatric hospital where she later confessed to her serial killing crimes.

Reports say that she had confessed on multiple occasions to friends and coworkers, all of whom had brushed it aside in disbelief. Wettlaufer, now 52, is serving eight concurrent life-sentences without parole for the next 25 years.

Context looked at health professionals who kill after Wettlaufer was arrested in 2016: