Exhibits

(Exhibits are available in English only)

List of Numbered Exhibits (those Exhibits that have been admitted into evidence)

Please note that some documents that have been filed as exhibits contain redactions for the purposes of privacy or public safety. In some cases, these redactions had already been applied before the Commission received the documents. In other cases, the Commission concluded it was necessary to make additional redactions before documents were filed at the Public Hearings.

Exhibit NumberNumbered Exhibits (those Exhibits that have been ruled admissible)Date Admitted
1Foundational Document – Agreed Statement of Facts
Appendix A to the Agreed Statement of Fact – Handwritten Confession
Appendix C to the Agreed Statement of Fact – Transcript of Elizabeth Wettlaufer's Police Statement
Appendix D to the Agreed Statement of Fact – Centre for Addiction and Mental Health (CAMH) - Discharge Data
June 5, 2018
2Foundational Document – Reasons for SentenceJune 5, 2018
3Foundational Document – Timeline of Major EventsJune 5, 2018
4Foundational Document – Legislation BriefJune 5, 2018
5Transcript of Interview with Elizabeth Wettlaufer
Appendix to Transcript
June 5, 2018
6Overview Report – The Facilities and Agencies
Facilities Overview Report – Report Source Documents
Please Note: this file is approx. 2gb and download speed will be dependant on your internet connection.
June 5, 2018
6ASupplementary Overview Report of the Facilities and Agencies
Supplementary Overview Report of the Facilities and Agencies – Report Source Documents
Please Note: this file is approx. 66Mb and download speed will be dependant on your internet connection.
August 8, 2018
7Overview Report – The Office of the Chief Coroner and the Ontario Forensic Pathology Service
Overview Report – Office of the Chief Coroner and OFPS - Report Source Documents
June 5, 2018
8Overview Report – The College of Nurses
Overview Report – The College of Nurses - Report Source Documents
Please Note: this file is approx. 400Mb and download speed will be dependant on your internet connection.
June 5, 2018
8AAddendum to the Overview Report of the College of Nurses of Ontario, single pageJuly 24, 2018
8BSecond Addendum to the Overview Report of the College of Nurses, including document LTCI00037056 (Summary of Telephone Call)August 8, 2018
9Overview Report – The Ministry of Health and Long-Term Care
Overview Report - Ministry of Health and Long-Term Care - Report Source Documents
Please Note: this file is approx. 21Gb and download speed will be dependant on your internet connection.
July 25, 2018
9AAddendum to the Overview Report of the Minsitry of Health and Long-Term CareJuly 30, 2018
9BSecond Addendum to the Overview Report of the Ministry of Health and Long-Term CareSeptember 14, 2018
10Affadivit of Brenda Van QuaethemJune 6, 2018
11Witness Documents for Brenda Van QuaethemJune 7, 2018
12Full Collective Agreement, expiring June 30, 2014June 7, 2018
13Guidelines for Eligible ExpendituresJune 7, 2018
14Table of Contents – Standards: Resident CareJune 7, 2018
15Policy and Procedure Document, Caressant Care, effective February, 2017June 7, 2018
16Affidavit of Helen Crombez, dated June 7, 2018June 7, 2018
17Interview summary by telephone, dated July 30, 2014June 8, 2018
18Registered Staff Meeting Minutes, dated July 29, 2010June 11, 2018
19Medication Management System Program Evaluation, dated September 2013June 11, 2018
20Witness documents for Helen CrombezJune 11, 2018
21Death Records re: Maurice GranatJune 11, 2018
22Caressant Care Policy and Procedure on Death of a ResidentJune 11, 2018
23Registered Staff Meeting Minutes, dated March 25, 2014June 11, 2018
24Resident Death or Transfer RecordJune 11, 2018
25Mandatory Reporting: a process guide for employers, facility operators and nurses, created by the College of Nurses of OntarioJune 11, 2018
26Registered Staff Contingency Plan for Working Short Staffed – August 19, 2013June 12, 2018
27Overtime Memo – April 19, 2013June 12, 2018
28Professional Responsibility Workload Report Form – December 20, 2010June 12, 2018
29Professional Responsibility Workload Report Form – April 1, 2011June 12, 2018
30Professional Responsibility Workload Report Form – June 16, 2013June 12, 2018
31Practice Guideline - RN and RPN Practice: The Client, the Nurse and the Environment - 2014June 12, 2018
32Inspection Report under the Long-Term Care Homes Act, 2007June 12, 2018
33Affidavit of Karen Routledge, dated June 12, 2018June 12, 2018
34Excerpt of Progress Notes re Maureen Pickering, dated September 9, 2013June 13, 2018
35Medical and Death Records of Maureen PickeringJune 13, 2018
36Collective Agreement dated June 30, 2011June 13, 2018
37Affidavit of Wendy MacKnott, dated June 13, 2018 June 13, 2018
38Affidavit of Heidi Wilmot-Smith, dated June 13, 2018June 13, 2018
39Lifeguard Homecare Service Contract and Agreement for Payment, dated July 24, 2015June 14, 2018
40Affidavit of Agatha Krawczyk, dated June 14, 2018June 14, 2018
41Affidavit of Brenda Black, dated June 14, 2018June 14, 2018
42Affidavit of Laura Long, dated June 18, 2018June 18, 2018
43Affidavit of Heather Nicholas, dated June 19, 2018June 19, 2018
44Time card for Elizabeth Wettlaufer at Meadow Park (Apr 30- May 3 2014)June 19, 2018
45Employee File Checklist – Jarlette Health Services (March 18, 2014 and March 19, 2014)June 19, 2018
46London Police Service Case Summary (Oct 4, 2017)June 19, 2018
47Witness Documents for Heather NicholasJune 19, 2018
48Affidavit of Melanie Smith, dated June 18, 2018June 20, 2018
49Jarlette Health Services Education Days - May 2014June 20, 2018
50Jarlette Health Services Education DaysJune 20, 2018
51Affidavit of Wanda Sanginesi, dated June 15, 2018June 20, 2018
52Residents' Council Meeting Minutes, December 18, 2013June 20, 2018
53Residents' Council Meeting Minutes, May 28 2014June 20, 2018
54Policy and Procedure - Job Description - Administrator - May 2013June 21, 2018
55Report Form for Facility Operators and Employers, March 31, 2014June 21, 2018
56Inspection Report under the Long-Term Care Homes ActJune 21, 2018
57Practice Standard - Medication, Revised 2008June 21, 2018
58Affidavit of Jill Allingham, dated June 18, 2018June 21, 2018
59ONA Grievance Fact SheetJune 21, 2018
60Affidavit of Robert Vanderheyden, dated June 18, 2018June 22, 2018
61Administrator Orientation ChecklistJune 22, 2018
62Inspection Report under the Long-Term Care Homes ActJune 22, 2018
63Medication - Inspection No 2014_229213_0072June 22, 2018
64Inspection Report under the Long-Term Care Homes ActJune 22, 2018
65Affidavit of John McDonald, dated June 22, 2018June 22, 2018
66Ad Hoc NotesJune 22, 2018
67Affidavit of Richard Reddick, dated June 22, 2018June 22, 2018
68 Affidavit of Joanne Polkiewicz, dated June 21, 2018June 22, 2018
69Affidavit of Vasilki (Lia) McInnes, dated June 18, 2018June 22, 2018
70Affidavit of Felina Cabrera, dated June 20, 2018June 22, 2018
71Affidavit of Cassidy Pizarro, dated June 18, 2018June 22, 2018
72Affidavit of Robyn Laycock, dated June 25, 2018June 25, 2018
73Affidavit of Jonathan Lu, dated June 25, 2018June 25, 2018
74OPA Best Practice Guidelines for Long-Term Care - Inspections of the Medication Management SystemJune 25, 2018
75Inspection Report under the Long-Term Care Homes ActJune 25, 2018
76Affidavit of Dianne Beauregard, dated June 25, 2018June 25, 2018
77Affidavit of Tracy Raney, dated June 25, 2018June 25, 2018
78Affidavit of Tanya Adams, dated June 24, 2018June 25, 2018
79Handwritten Notes (Sept-Oct 2014)June 25, 2018
80Standards for Pharmacists Providing Services to Licensed Long-Term Care Facilities, effective January 1, 2007June 26, 2018
81Affidavit of Dian Shannon, dated June 26, 2018June 26, 2018
82Ministry of Health and Long-Term Care Inspection Report, dated May 24, 2017June 26, 2018
83Ministry of Health and Long-Term Care, Order(s) of the Inspector, dated Mar 8, 2016June 26, 2018
84Affidavit of Sherri Toleff, dated June 26, 2018June 26, 2018
85Affidavit of Michelle Cornelissen, dated June 26, 2018June 26, 2018
86Affidavit of Carol Hepting, dated June 25, 2018June 27, 2018
87Order of the DirectorJune 27, 2018
88Suspension of Admissions to Caressant Care Woodstock Nursing HomeJune 27, 2018
89Suspension of Admissions to Caressant Care Woodstock (Lifted)June 27, 2018
90Affidavit of Tamara Condy, dated June 27, 2018June 27, 2018
91Resume of Elizabeth WettlauferJune 27, 2018
92Resume of Elizabeth WettlauferJune 27, 2018
93Feedback ReportJune 27, 2018
94Affidavit of Patricia Malone, dated June 27, 2018June 28, 2018
95Supplementary Affidavit of Helen Crombez, dated June 28, 2018June 28, 2018
96Affidavit of Laura Jackson, dated June 27, 2018June 28, 2018
97Affidavit of Noelle Kelly, dated June 13, 2018July 16, 2018
98Affidavit of Dr. Dirk Huyer, dated July 3, 2018July 16, 2018
99Death Investigation Oversight Council DocumentJuly 16, 2018
100Case Selection Data FormJuly 16, 2018
101Chapter 3 Investigations - GeneralJuly 16, 2018
102Chapter 4 Guidelines for Death InvestigationsJuly 16, 2018
103Chapter 5 Apparently Natural DeathsJuly 17, 2018
104Affidavit of Dr. G. Richard MannJuly 17, 2018
105Performance Evaluation for Investigating CoronersJuly 17, 2018
106Summary of Dr. William George’s ResumeJuly 18, 2018
107Resident Death or Transfer Record for Caressant Care WoodstockJuly 18, 2018
108Coroner Investigation WorksheetJuly 18, 2018
109Preliminary Report - History & PhysicalJuly 18, 2018
110Caressant Care Resident Information Form for Mr. Silcox, pages 3-4July 18, 2018
111Curriculum Vitae of Dr. Elizabeth UrbantkeJuly 19, 2018
112Handwritten Notes, page 3, January 24thJuly 19, 2018
113Coroner's Investigation Statement (Form 3) dated 2013July 19, 2018
114Form 3 Coroner’s Investigation Statement, by Dr. UrbantkeJuly 19, 2018
115Affidavit of Dianne Crawford, dated July 22, 2018July 23, 2018
116Affidavit of Dr. Michael Pollanen, dated July 6, 2018July 23, 2018
117Diagnostic Imaging Consultation Report, page 102July 23, 2018
118The Forensic Pathology of Secret Homicides: A Retrospective ReviewJuly 23, 2018
119The Forensic Pathology of Secret Homicides: A Retrospective Review-PowerPointJuly 23, 2018
120Strengths of Ontario Investigation Systems, Draft for Discussion Purposes Only, pages 59-61July 24, 2018
121Affidavit of Anne Coghlan, dated July 3, 2018July 24, 2018
121ACollege of Nurses Document Brief, Tabs 1-50August 8, 2018
1222017 Annual Report of the College of Nurses: Leading in ChangeJuly 24, 2018
123CNO Organizational StructureJuly 24, 2018
124Prevalence and Nature of Medication Administration Errors in Health Care SettingsJuly 24, 2018
125Recidivism of Nurses Subject to a Report from an EmployerJuly 25, 2018
126Bill 87, Protecting Patients Act, 2017July 26, 2018
127OMA Mission/Objectives to the PHP ProgramJuly 26, 2018
128Identifying Risks: Learnings from the literature on health care serial killersJuly 26, 2018
129Affidavit of Karen Simpson, dated July 25, 2018
Please Note: this file is approx. 158Mb and download speed will be dependant on your internet connection.
July 30, 2018
130Evidence of Philip Moorman: Long-Term Care Homes Quality Inspection Program Performance Assessment (LPA)July 30, 2018
131LTCHomes.net Memo to the Sector: Annual Provincial Data for 2017 RQIJuly 31, 2018
132Two documents:
Letter dated February 7, 2017 to Karen Simpson from Caressant Care
Several-page attachment to the letter
July 31, 2018
133Letter to Long-Term Care home Licensees, dated January 11, 2017July 31, 2018
134Affidavit of Rhonda Kukoly, dated July 24, 2018August 1, 2018
135Report on the inquest into the deaths of Ezzeldine El Roubi and Pedro LopezAugust 1, 2018
136Inspection Report dated June 29, 2017August 1, 2018
137Caressant Care Registered Staff Interview of Karen Routledge, dated December 13, 2016August 2, 2018
138Medication Management System Program EvaluationAugust 2, 2018
139Medication Management System Program EvaluationAugust 2, 2018
140Medication Management System Program EvaluationAugust 2, 2018
141Interview of Sandra FluttertAugust 2, 2018
142Affidavit of Natalie Moroney, dated July 24, 2018August 2, 2018
143Staff Inventory List for Meadow Park London, date of Inspection October 28, 2016August 3, 2018
144Affidavit of Lisa VinkAugust 3, 2018
145Staff Inventory List, dated October 5, 2016 (2 pages)August 3, 2018
146Ministry of Health and Long-Term Care Resident Quality Inspection, dated August 3, 2017August 3, 2018
147Affidavit of Aislinn McNally, dated July 26, 2018August 7, 2018
148Affidavit of Phillip Moorman, dated July 27, 2018August 7, 2018
149Letter dated October 13, 2016 from Meadow Park LondonAugust 7, 2018
150Overall Results for Jarlette Health Services- Meadow Park London Long Term CareAugust 7, 2018
151Abaqis Customer Satisfaction Report, Resident Satisfaction, Meadow Park LondonAugust 7, 2018
152Abaqis Customer Satisfaction Report, Family Satisfaction, Meadow Park LondonAugust 7, 2018
153Extract from Ontario website: Find long-term care homes in OntarioAugust 7, 2018
154Affidavit of Karen Fairchild, dated July 31, 2018August 7, 2018
155Former Exhibit "A" Transcript of an interview by Rhonda Kukoly of Laura LongAugust 8, 2018
156Long-Term Care Homes Quality Inspection Program for Ontario Presentation to OARC Board of Directors, dated November 2, 2010August 8, 2018
157Long-Term Care Homes Quality Inspection Program for Ontario Presentation to Ontario Nurses Association, dated December 7, 2010August 8, 2018
158Price Waterhouse Coopers: Report of a Study to Review Levels of Service and Responses to Need in a sample of Ontario Long Term Care Facilities and Selected Comparators, dated January 11, 2001August 8, 2018
159Affidavit of Karen Mitchell, dated July 19, 2018August 8, 2018
160Affidavit of Donna Ladouceur, dated July 27, 2018August 8, 2018
161Affidavit of Steven Carswell, dated July 31, 2018August 9, 2018
162CCAC Audit ChartAugust 9, 2018
163Expert Report of Professor Beatrice Crofts YorkerSeptember 12, 2018
164Killer practitioners: What can you do to stop them?September 12, 2018
165Progress and Precision: The NCSBN 2018 Environmental ScanSeptember 12, 2018
166Expert Report of Ms. Julie GreenallSeptember 13, 2018
167Witness Statement of John McDonaldSeptember 14, 2018
168Affidavit of Dr. Michael Hillmer, dated August 29, 2018September 14, 2018
169Long-Term Care in Ontario - Sector overviewSeptember 14, 2018
170Detecting LTC Homes with Excessive Rate of MortalitySeptember 14, 2018
171Shipman's statistical legacySeptember 14, 2018

List of Lettered Exhibits (those Exhibits that have been referred to but not yet ruled on)

Exhibit LetterExhibit TitleDate TenderedExhibit Number Assigned
(if ruled admissible)
ATranscript of Interview with Laura Long, dated November 15, 2016June 13, 2018155
BEvent Search, dates March 8, 2014June 13, 201897, 98
CCaressant Care Registered Staff Interview of Karen Routledge, dated December 13, 2016June 13, 2018137
DHandwritten Notes dated May 6, 2014June 21, 201858
EEmail to Jill Allingham, dated May 22, 2014 from Wanda SanginesiJune 21, 20186
FCaressant Care Critical Incident Notes by Rhonda KukolyJuly 18, 20189
(LTCI00043003)
GMemo - College of Nurses of OntarioJuly 27, 2018121A
(LTCI00072833)