The criminal justice system is a crucial aspect of the Canadian
legal system; however, it has limitations. A criminal proceeding is
not equipped to examine root causes or outline possible corrective
measures. This is well illustrated in the case involving the tragic
murders and attempted murders of long-term care patients by
Elizabeth Wettlaufer, a registered nurse, between 2007 and 2016.
Wettlaufer knowingly and wrongfully injected 14 senior citizens
with insulin, causing their death or injury. The case not only
resulted in criminal proceedings, but also initiated a broad and
in-depth public inquiry into the safety and security of residents
in the long-term care home system. That inquiry (The Long-Term Care
Homes Public Inquiry) started in August of 2017 and the final
report and recommendations were released in July of this year. Even
though the report was a mandate of the Government of Ontario, and
reviewed some items specific to processes and reporting in
