There are 91 recommendations coming from an inquiry looking at how to prevent seniors from being murdered in long term care homes.
The inquiry commissioner, Eileen Gillese, blames a systemic failure which allowed Elizabeth Wettlaufer to kill eight patients in southern Ontario from 2007-2016.
Gillese suggests the system is not designed to catch senior’s home employees who go rogue.
The commissioner says for that reason, it will take a long time to make changes since it was only because of Wettlaufer’s confession, her crimes were revealed.
Prosecutors admit Wettlaufer might never had been caught if she had not come forward and confessed.