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 Number	Numbered Exhibits (those Exhibits that have been ruled admissible)	Date Admitted
1	Foundational 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
2	Foundational Document – Reasons for Sentence	June 5, 2018
3	Foundational Document – Timeline of Major Events	June 5, 2018
4	Foundational Document – Legislation Brief	June 5, 2018
5	Transcript of Interview with Elizabeth Wettlaufer Appendix to Transcript	June 5, 2018
6	Overview 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
6A	Supplementary 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
7	Overview 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
8	Overview 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
8A	Addendum to the Overview Report of the College of Nurses of Ontario, single page	July 24, 2018
8B	Second Addendum to the Overview Report of the College of Nurses, including document LTCI00037056 (Summary of Telephone Call)	August 8, 2018
9	Overview 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
9A	Addendum to the Overview Report of the Minsitry of Health and Long-Term Care	July 30, 2018
9B	Second Addendum to the Overview Report of the Ministry of Health and Long-Term Care Second Addendum to the Overview Report of the Ministry of Health and Long-Term Care - Report Source Documents	September 14, 2018
10	Affadivit of Brenda Van Quaethem	June 6, 2018
11	Witness Documents for Brenda Van Quaethem	June 7, 2018
12	Full Collective Agreement, expiring June 30, 2014	June 7, 2018
13	Guidelines for Eligible Expenditures	June 7, 2018
14	Table of Contents – Standards: Resident Care	June 7, 2018
15	Policy and Procedure Document, Caressant Care, effective February, 2017	June 7, 2018
16	Affidavit of Helen Crombez, dated June 7, 2018	June 7, 2018
17	Interview summary by telephone, dated July 30, 2014	June 8, 2018
18	Registered Staff Meeting Minutes, dated July 29, 2010	June 11, 2018
19	Medication Management System Program Evaluation, dated September 2013	June 11, 2018
20	Witness documents for Helen Crombez	June 11, 2018
21	Death Records re: Maurice Granat	June 11, 2018
22	Caressant Care Policy and Procedure on Death of a Resident	June 11, 2018
23	Registered Staff Meeting Minutes, dated March 25, 2014	June 11, 2018
24	Resident Death or Transfer Record	June 11, 2018
25	Mandatory Reporting: a process guide for employers, facility operators and nurses, created by the College of Nurses of Ontario	June 11, 2018
26	Registered Staff Contingency Plan for Working Short Staffed – August 19, 2013	June 12, 2018
27	Overtime Memo – April 19, 2013	June 12, 2018
28	Professional Responsibility Workload Report Form – December 20, 2010	June 12, 2018
29	Professional Responsibility Workload Report Form – April 1, 2011	June 12, 2018
30	Professional Responsibility Workload Report Form – June 16, 2013	June 12, 2018
31	Practice Guideline - RN and RPN Practice: The Client, the Nurse and the Environment - 2014	June 12, 2018
32	Inspection Report under the Long-Term Care Homes Act, 2007	June 12, 2018
33	Affidavit of Karen Routledge, dated June 12, 2018	June 12, 2018
34	Excerpt of Progress Notes re Maureen Pickering, dated September 9, 2013	June 13, 2018
35	Medical and Death Records of Maureen Pickering	June 13, 2018
36	Collective Agreement dated June 30, 2011	June 13, 2018
37	Affidavit of Wendy MacKnott, dated June 13, 2018	June 13, 2018
38	Affidavit of Heidi Wilmot-Smith, dated June 13, 2018	June 13, 2018
39	Lifeguard Homecare Service Contract and Agreement for Payment, dated July 24, 2015	June 14, 2018
40	Affidavit of Agatha Krawczyk, dated June 14, 2018	June 14, 2018
41	Affidavit of Brenda Black, dated June 14, 2018	June 14, 2018
42	Affidavit of Laura Long, dated June 18, 2018	June 18, 2018
43	Affidavit of Heather Nicholas, dated June 19, 2018	June 19, 2018
44	Time card for Elizabeth Wettlaufer at Meadow Park (Apr 30- May 3 2014)	June 19, 2018
45	Employee File Checklist – Jarlette Health Services (March 18, 2014 and March 19, 2014)	June 19, 2018
46	London Police Service Case Summary (Oct 4, 2017)	June 19, 2018
47	Witness Documents for Heather Nicholas	June 19, 2018
48	Affidavit of Melanie Smith, dated June 18, 2018	June 20, 2018
49	Jarlette Health Services Education Days - May 2014	June 20, 2018
50	Jarlette Health Services Education Days	June 20, 2018
51	Affidavit of Wanda Sanginesi, dated June 15, 2018	June 20, 2018
52	Residents' Council Meeting Minutes, December 18, 2013	June 20, 2018
53	Residents' Council Meeting Minutes, May 28 2014	June 20, 2018
54	Policy and Procedure - Job Description - Administrator - May 2013	June 21, 2018
55	Report Form for Facility Operators and Employers, March 31, 2014	June 21, 2018
56	Inspection Report under the Long-Term Care Homes Act	June 21, 2018
57	Practice Standard - Medication, Revised 2008	June 21, 2018
58	Affidavit of Jill Allingham, dated June 18, 2018	June 21, 2018
59	ONA Grievance Fact Sheet	June 21, 2018
60	Affidavit of Robert Vanderheyden, dated June 18, 2018	June 22, 2018
61	Administrator Orientation Checklist	June 22, 2018
62	Inspection Report under the Long-Term Care Homes Act	June 22, 2018
63	Medication - Inspection No 2014_229213_0072	June 22, 2018
64	Inspection Report under the Long-Term Care Homes Act	June 22, 2018
65	Affidavit of John McDonald, dated June 22, 2018	June 22, 2018
66	Ad Hoc Notes	June 22, 2018
67	Affidavit of Richard Reddick, dated June 22, 2018	June 22, 2018
68	Affidavit of Joanne Polkiewicz, dated June 21, 2018	June 22, 2018
69	Affidavit of Vasilki (Lia) McInnes, dated June 18, 2018	June 22, 2018
70	Affidavit of Felina Cabrera, dated June 20, 2018	June 22, 2018
71	Affidavit of Cassidy Pizarro, dated June 18, 2018	June 22, 2018
72	Affidavit of Robyn Laycock, dated June 25, 2018	June 25, 2018
73	Affidavit of Jonathan Lu, dated June 25, 2018	June 25, 2018
74	OPA Best Practice Guidelines for Long-Term Care - Inspections of the Medication Management System	June 25, 2018
75	Inspection Report under the Long-Term Care Homes Act	June 25, 2018
76	Affidavit of Dianne Beauregard, dated June 25, 2018	June 25, 2018
77	Affidavit of Tracy Raney, dated June 25, 2018	June 25, 2018
78	Affidavit of Tanya Adams, dated June 24, 2018	June 25, 2018
79	Handwritten Notes (Sept-Oct 2014)	June 25, 2018
80	Standards for Pharmacists Providing Services to Licensed Long-Term Care Facilities, effective January 1, 2007	June 26, 2018
81	Affidavit of Dian Shannon, dated June 26, 2018	June 26, 2018
82	Ministry of Health and Long-Term Care Inspection Report, dated May 24, 2017	June 26, 2018
83	Ministry of Health and Long-Term Care, Order(s) of the Inspector, dated Mar 8, 2016	June 26, 2018
84	Affidavit of Sherri Toleff, dated June 26, 2018	June 26, 2018
85	Affidavit of Michelle Cornelissen, dated June 26, 2018	June 26, 2018
86	Affidavit of Carol Hepting, dated June 25, 2018	June 27, 2018
87	Order of the Director	June 27, 2018
88	Suspension of Admissions to Caressant Care Woodstock Nursing Home	June 27, 2018
89	Suspension of Admissions to Caressant Care Woodstock (Lifted)	June 27, 2018
90	Affidavit of Tamara Condy, dated June 27, 2018	June 27, 2018
91	Resume of Elizabeth Wettlaufer	June 27, 2018
92	Resume of Elizabeth Wettlaufer	June 27, 2018
93	Feedback Report	June 27, 2018
94	Affidavit of Patricia Malone, dated June 27, 2018	June 28, 2018
95	Supplementary Affidavit of Helen Crombez, dated June 28, 2018	June 28, 2018
96	Affidavit of Laura Jackson, dated June 27, 2018	June 28, 2018
97	Affidavit of Noelle Kelly, dated June 13, 2018	July 16, 2018
98	Affidavit of Dr. Dirk Huyer, dated July 3, 2018	July 16, 2018
99	Death Investigation Oversight Council Document	July 16, 2018
100	Case Selection Data Form	July 16, 2018
101	Chapter 3 Investigations - General	July 16, 2018
102	Chapter 4 Guidelines for Death Investigations	July 16, 2018
103	Chapter 5 Apparently Natural Deaths	July 17, 2018
104	Affidavit of Dr. G. Richard Mann	July 17, 2018
105	Performance Evaluation for Investigating Coroners	July 17, 2018
106	Summary of Dr. William George’s Resume	July 18, 2018
107	Resident Death or Transfer Record for Caressant Care Woodstock	July 18, 2018
108	Coroner Investigation Worksheet	July 18, 2018
109	Preliminary Report - History & Physical	July 18, 2018
110	Caressant Care Resident Information Form for Mr. Silcox, pages 3-4	July 18, 2018
111	Curriculum Vitae of Dr. Elizabeth Urbantke	July 19, 2018
112	Handwritten Notes, page 3, January 24th	July 19, 2018
113	Coroner's Investigation Statement (Form 3) dated 2013	July 19, 2018
114	Form 3 Coroner’s Investigation Statement, by Dr. Urbantke	July 19, 2018
115	Affidavit of Dianne Crawford, dated July 22, 2018	July 23, 2018
116	Affidavit of Dr. Michael Pollanen, dated July 6, 2018	July 23, 2018
117	Diagnostic Imaging Consultation Report, page 102	July 23, 2018
118	The Forensic Pathology of Secret Homicides: A Retrospective Review	July 23, 2018
119	The Forensic Pathology of Secret Homicides: A Retrospective Review-PowerPoint	July 23, 2018
120	Strengths of Ontario Investigation Systems, Draft for Discussion Purposes Only, pages 59-61	July 24, 2018
121	Affidavit of Anne Coghlan, dated July 3, 2018	July 24, 2018
121A	College of Nurses Document Brief, Tabs 1-50	August 8, 2018
122	2017 Annual Report of the College of Nurses: Leading in Change	July 24, 2018
123	CNO Organizational Structure	July 24, 2018
124	Prevalence and Nature of Medication Administration Errors in Health Care Settings	July 24, 2018
125	Recidivism of Nurses Subject to a Report from an Employer	July 25, 2018
126	Bill 87, Protecting Patients Act, 2017	July 26, 2018
127	OMA Mission/Objectives to the PHP Program	July 26, 2018
128	Identifying Risks: Learnings from the literature on health care serial killers	July 26, 2018
129	Affidavit 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
130	Evidence of Philip Moorman: Long-Term Care Homes Quality Inspection Program Performance Assessment (LPA)	July 30, 2018
131	LTCHomes.net Memo to the Sector: Annual Provincial Data for 2017 RQI	July 31, 2018
132	Two documents: Letter dated February 7, 2017 to Karen Simpson from Caressant Care Several-page attachment to the letter	July 31, 2018
133	Letter to Long-Term Care home Licensees, dated January 11, 2017	July 31, 2018
134	Affidavit of Rhonda Kukoly, dated July 24, 2018	August 1, 2018
135	Report on the inquest into the deaths of Ezzeldine El Roubi and Pedro Lopez	August 1, 2018
136	Inspection Report dated June 29, 2017	August 1, 2018
137	Caressant Care Registered Staff Interview of Karen Routledge, dated December 13, 2016	August 2, 2018
138	Medication Management System Program Evaluation	August 2, 2018
139	Medication Management System Program Evaluation	August 2, 2018
140	Medication Management System Program Evaluation	August 2, 2018
141	Interview of Sandra Fluttert	August 2, 2018
142	Affidavit of Natalie Moroney, dated July 24, 2018	August 2, 2018
143	Staff Inventory List for Meadow Park London, date of Inspection October 28, 2016	August 3, 2018
144	Affidavit of Lisa Vink	August 3, 2018
145	Staff Inventory List, dated October 5, 2016 (2 pages)	August 3, 2018
146	Ministry of Health and Long-Term Care Resident Quality Inspection, dated August 3, 2017	August 3, 2018
147	Affidavit of Aislinn McNally, dated July 26, 2018	August 7, 2018
148	Affidavit of Phillip Moorman, dated July 27, 2018	August 7, 2018
149	Letter dated October 13, 2016 from Meadow Park London	August 7, 2018
150	Overall Results for Jarlette Health Services- Meadow Park London Long Term Care	August 7, 2018
151	Abaqis Customer Satisfaction Report, Resident Satisfaction, Meadow Park London	August 7, 2018
152	Abaqis Customer Satisfaction Report, Family Satisfaction, Meadow Park London	August 7, 2018
153	Extract from Ontario website: Find long-term care homes in Ontario	August 7, 2018
154	Affidavit of Karen Fairchild, dated July 31, 2018	August 7, 2018
155	Former Exhibit "A" Transcript of an interview by Rhonda Kukoly of Laura Long	August 8, 2018
156	Long-Term Care Homes Quality Inspection Program for Ontario Presentation to OARC Board of Directors, dated November 2, 2010	August 8, 2018
157	Long-Term Care Homes Quality Inspection Program for Ontario Presentation to Ontario Nurses Association, dated December 7, 2010	August 8, 2018
158	Price 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, 2001	August 8, 2018
159	Affidavit of Karen Mitchell, dated July 19, 2018	August 8, 2018
160	Affidavit of Donna Ladouceur, dated July 27, 2018	August 8, 2018
161	Affidavit of Steven Carswell, dated July 31, 2018	August 9, 2018
162	CCAC Audit Chart	August 9, 2018
163	Expert Report of Professor Beatrice Crofts Yorker	September 12, 2018
164	Killer practitioners: What can you do to stop them?	September 12, 2018
165	Progress and Precision: The NCSBN 2018 Environmental Scan	September 12, 2018
166	Expert Report of Ms. Julie Greenall	September 13, 2018
167	Witness Statement of John McDonald	September 14, 2018
168	Affidavit of Dr. Michael Hillmer, dated August 29, 2018	September 14, 2018
169	Long-Term Care in Ontario - Sector overview	September 14, 2018
170	Detecting LTC Homes with Excessive Rate of Mortality	September 14, 2018
171	Shipman's statistical legacy	September 14, 2018

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

Exhibit Letter	Exhibit Title	Date Tendered	Exhibit Number Assigned (if ruled admissible)
A	Transcript of Interview with Laura Long, dated November 15, 2016	June 13, 2018	155
B	Event Search, dates March 8, 2014	June 13, 2018	97, 98
C	Caressant Care Registered Staff Interview of Karen Routledge, dated December 13, 2016	June 13, 2018	137
D	Handwritten Notes dated May 6, 2014	June 21, 2018	58
E	Email to Jill Allingham, dated May 22, 2014 from Wanda Sanginesi	June 21, 2018	6
F	Caressant Care Critical Incident Notes by Rhonda Kukoly	July 18, 2018	9 (LTCI00043003)
G	Memo - College of Nurses of Ontario	July 27, 2018	121A (LTCI00072833)