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Order in Council

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Order in Council

Ministry of the Attorney General

Ontario has appointed the Honourable Justice Eileen Gillese, a judge of the Ontario Court of Appeal, to lead an independent public inquiry in to the practices, policies, procedures and oversight of long-term care homes.

An Order in Council has been filed detailing the mandate of the public inquiry. It reads as follows:

WHEREAS under the Public Inquiries Act, 2009, the Lieutenant Governor in Council may appoint a person to inquire into any matter of public interest;

AND WHEREAS on June 1, 2017, Elizabeth Wettlaufer pled guilty to and was convicted of eight counts of first degree murder, four counts of attempted murder and two counts of aggravated assault (the "Offences"), these Offences having been committed while working as a registered nurse in southwestern Ontario;

AND WHEREAS it is desirable to ensure that Ontario's long-term care homes system meets the objectives of the Long-Term Care Homes Act, 2007, to ensure the safety and well-being of residents of long-term care homes in Ontario;

AND WHEREAS it is considered desirable and in the public interest for the Ontario Government to appoint a person to identify and make recommendations to address systemic failings in Ontario's long-term care homes system that may have occurred in connection with the Offences;

AND WHEREAS it is considered advisable to set out the terms of reference for such process and recommendations;

THEREFORE, pursuant to the Public Inquiries Act, 2009 it is ordered as follows:


  1. A Commission is established and the Honourable Justice Eileen Gillese is appointed as a commissioner under section 3 of the Public Inquiries Act, 2009, (the "Commissioner"), effective as of August 1, 2017.


  1. Having regard to section 5 of the Public Inquiries Act, 2009, the Commission shall inquire into:
    1. the events which led to the Offences
    2. the circumstances and contributing factors allowing these events to occur, including the effect, if any, of relevant policies, procedures, practices, and accountability and oversight mechanisms, and
    3. other relevant matters that the Commissioner considers necessary to avoid similar tragedies.
  2. The Commissioner shall perform her duties without expressing any conclusion or recommendations regarding the potential civil or criminal liability of any person or organization. The Commissioner shall further ensure that the conduct of the inquiry does not in any way interfere or conflict with any ongoing investigation or legal proceeding related to these matters.
  3. Where the Commissioner considers it essential and at her discretion, she may engage in any activity appropriate to fulfilling her duties, including:
    1. Conducting research and collecting information, including conducting interviews and undertaking surveys
    2. Conducting inter-jurisdictional research to identify practices in other jurisdictions that are relevant to this inquiry
    3. Consulting with, or seeking submissions from, key stakeholders and sector experts
    4. Consulting with the general public, including consulting prior to making its rules or determining who may participate in the public inquiry, and
    5. Receiving oral and written submissions.
  4. The Commission shall, as much as practicable and appropriate, refer to and rely on the matters set out in section 9 of the Public Inquiries Act, 2009. In particular, the Commission shall review and consider any existing records or reports relevant to its mandate, including the court records of the Wettlaufer criminal proceedings, and other medical, professional and business records. Further, the Commission shall rely wherever possible on overview reports submitted to or created or written by the inquiry. The Commission may consider such reports and records in lieu of calling witnesses.
  5. Pursuant to section 14 of the Public Inquiries Act, 2009, the Commission may hold public hearings as necessary to fulfill its mandate.
  6. The Commission may exercise the powers provided for in section 13 of the Public Inquiries Act, 2009.
  7. The Commission shall, wherever practicable, rely on representative witnesses on behalf of institutions and may convene and/or consult with panels of representative witnesses in order to fulfill its mandate in a timely manner.
  8. In accordance with the Public Inquiries Act, 2009, the Commissioner shall obtain all records necessary to perform her duties and, for that purpose, may require the production of information that is confidential or inadmissible under any Act or regulation.
  9. Where the Commissioner considers it necessary, she may impose conditions on the disclosure of information in order to protect the confidentiality of that information. In so far as practicable, the Commissioner shall work to maintain and ensure the confidentiality of personal health information.
  10. The Commissioner shall follow Management Board of Cabinet directives and guidelines and other applicable government policies unless, in the Commissioner's view and having regard to her mandate, it is not possible to follow them.
  11. The Commission shall promote accessibility and transparency to the public through the use of technology, including by establishing and maintaining a website.


  1. The Commissioner may make recommendations to the Attorney General regarding funding to participants in the inquiry to the extent of that participant's interest where, in the Commissioner's view, the participants would not otherwise be able to participate in the inquiry without such funding. Such funding shall be in accordance with applicable Management Board of Cabinet directives and guidelines.


  1. The Commissioner shall endeavor to conclude her mandate and deliver a final report to the Attorney General summarizing her activities and including any recommendations no later than 24 months after the establishment of the Commission.
  2. In delivering her final report to the Attorney General, the Commissioner shall ensure, in so far as practicable, that it is in a form appropriate for public release, consistent with the requirements of the Freedom of Information and Protection of Privacy Act and other applicable legislation.
  3. The Commissioner shall be responsible for translation and printing and shall ensure that her final report is delivered in English and in French, at the same time, in electronic and printed versions.

Financial and Administrative Matters

  1. The financial and administrative support necessary to enable the Commission to fulfill its mandate shall be provided in accordance with sections 25, 26 and 27 of the Public Inquiries Act, 2009.
  2. All ministries and all boards, agencies and commissions of the Government of Ontario shall, subject to any privilege or other legal restrictions, assist the Commission to the fullest extent possible, including producing documents in a timely manner, so that the Commission may carry out its duties.
  3. The Attorney General shall make the Commissioner's final report available to the public as soon as practicable after receiving it.

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