All About Estates

Homicide in Ontario LTC Homes

Readers in Ontario are likely familiar with Elizabeth Tracy Mae Wettlaufer, a former registered nurse, who confessed to murdering eight senior citizens and attempting to murder six others in southwestern Ontario long term care (LTC) homes between 2007 and 2016. Following her criminal conviction, the province of Ontario established a Public Inquiry into the Safety and Security of Residents in the Long-term Care Homes System led by Justice Eileen Gillese. Justice Gillese’s report, which was released at the end of July 2019, made 91 recommendations to address systemic vulnerabilities in the long-term care system which, if implemented, would help prevent, deter, and detect murder of LTC residents by health-care workers.[i]

From 1988 to 2004, there were 14 reported homicides of patients by other patients in licensed LTC homes in Ontario.[ii] From 2001 to 2013, that number went up to 27.[iii] Justice Gillese’s report is the most recent development in the province’s efforts to adapt to the growing needs of LTC homes in Ontario.

On June 4, 1997, Max Zulauf, a 74-year-old man with dementia, set fire to a mattress causing a tragic fire and resulting in three fatalities in the K-wing of Sunnybrook Health Sciences Centre, a seniors’ home for war veterans.[iv] A coroner’s inquest into the fire made several recommendations to deal with the growing problems of aggression in dementia patients. Among others, the coroner’s jury recommended that the city, the province, and Veterans Affairs put money into Behaviour Units to take care of the growing aging population that suffer from dementia and aggressive responsive behaviours.

In 2001, Sunnybrook opened the Dorothy Macham Home, a 10-bed behavioural unit to treat veterans with dementia and behavioural problems. Nine years later, in 2010, the first Special Behaviour Support Unit (SBSU) in public LTC homes in Ontario was opened at Sheridan Villa LTC in Mississauga. The SBSU is a 19 bed unit designed to provide transitional treatment and stabilization for individuals with a primary diagnosis of dementia and unpredictable and aggressive responsive behaviours who cannot be effectively managed within a typical LTC home unit. Since then, at least four similar units have opened in Ontario: at Baycrest in Toronto; Cummer Lodge LTC home in North York; McGarrell Place LTC Home in London; and Cooksville Care Centre LTC in Mississauga. (I am the Geriatric Psychiatry consultant to the Sheridan Villa and Cooksville Care Centre units.)

The Ontario Behaviour Support System (BSS) Project was also launched by the Ontario Ministry of Health and Long-Term Care in 2010 to improve outcomes for persons with challenging responsive behaviours associated with dementia. The program aims to support patients, their families, health providers and the healthcare system including LTC. This program works in conjunction with the Alzheimer Society.

Most recently, the Butterfly Household Model of Care has been developed as a means to improve non-pharmacologic strategies to further reduce responsive behavioural problems in residents with dementia in LTC.

Despite these steps forward, in January 2014, Donna Rubin, CEO of the Ontario Association of Non Profit Homes and Services for Seniors (now called AdvantAge Ontario), warned a legislative committee at Queen’s Park that LTC homes lack the funding to hire enough staff to keep residents safe. Rubin told MPPs that every long-term-care administrator “knows that [a homicide] could happen in their home.” Rubin was also quoted as saying “for years, we have been signaling that we do not have enough direct-care staff on the floor and the staff we have is not adequately trained to properly care for residents with aggressive and unpredictable behaviours.”

The reality is that the prevention of a homicide in LTC remains beyond the control of any one healthcare worker. However, systemic efforts are underway to make LTC homes safer.


[i] CBC News. Posted: Jul 31, 2019. “’Systemic vulnerabilities’ let killer nurse Elizabeth Wettlaufer keep on killing — report.” Available at

[ii] Globe and Mail. Saturday, Nov. 13 2004. “To protect residents of nursing homes.” Available at

[iii] Theresa Boyle Health, The Toronto Star, Published on Sun Feb 16 2014 available at

[iv] CBC News.  Posted: Sep 24, 1999. Sunnybrooke jury releases recommendations. available at


About Dr. Richard Shulman
Dr. Shulman is a geriatric psychiatrist at Trillium Health Partners and is an assistant professor at the University of Toronto. He is medical director of the Capacity Clinic and available for independent medical-legal capacity assessments.


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