“The evidence in this inquiry shows that nothing would have triggered an investigation into Wettlaufer or the incidents underlying the offenses,” Commissioner Eileen E. Gillese told family members, officials and reporters here, not far from the Caressant Care nursing home where seven of Wettlaufer’s victims died.“This finding is significant because it tells us that to prevent similar tragedies in the future, we cannot continue to do the same things in the same ways in the long-term care system.”

Injecting insulin into a person who doesn’t need it can cause that person’s blood sugar to drop below the normal range. Even if the deaths of Wettlaufer’s victims had been fully investigated, Gillese wrote, it is unlikely they would have produced evidence indicating her guilt.

The commissioner, an appellate court judge in Ontario, had the authority to make findings of individual misconduct. But she declined, instead blaming “systemic vulnerabilities in the long-term care system” for which there is “no simple fix.”

Gillese issued 91 nonbinding recommendations, including calls to strengthen the management of medications at long-term care homes, bolster background and reference checks for prospective employees, and increase funding for nursing staff when necessary.

Merrilee Fullerton, Ontario’s minister for long-term care, said she would review the recommendations and submit a report next year detailing progress implementing them. She promised that the government would set aside new funding to address systemic issues.

“Today is a solemn day, and I want to acknowledge the pain and the trauma this tragedy has caused and the impact it has had in the province,” she said. “To the families, I want to say, your loved ones mattered, they had meaning, and they will make a difference.”

Helen Matheson, 95, died at Caressant Care in October 2011. She was Wettlaufer’s fourth victim. Her son watched on Wednesday as Gillese delivered the inquiry findings.

“All I can hope for is that what is recommended in the report becomes part of law,” John Matheson said.

Wettlaufer pleaded guilty to first-degree murder in the deaths of the eight seniors, four counts of attempted murder and two counts of aggravated assault. She is serving life in prison.

“The fact that Wettlaufer is behind bars does not mean that we are safe from health care serial killers,” Gillese wrote. “It means only that we are safe from her.”

Wettlaufer checked herself into a mental health hospital in Toronto in 2016 and began to talk about the killings with her psychiatrist. She wrote a four-page confession that prompted the hospital to contact police.

Wettlaufer detailed how she killed each of her victims to police. After her marriage fell apart in 2007, she said, she was “just angry in general . . . at my job . . . at my life.”

When she felt what she called “the red surge” come over her, she would kill. Each death, she said, brought a feeling of “euphoria.”

The Ontario government launched its inquiry after Wettlaufer’s sentencing hearing in 2017. Over two years, the inquiry took testimony from about 50 witnesses and reviewed more than 42,000 documents.

Wettlaufer’s colleagues began sounding alarms about her from 1995 — the year she began her nursing career — and continued until 2016, when she confessed.

But the red flags weren’t enough to stop her from getting work, Gillese wrote. The ages of her victims, between 75 and 96, made them easy prey; few suspected that the deaths were anything but natural.

“When Wettlaufer committed the offenses, the victims were still enjoying their lives and their loved ones were still enjoying time with them,” Gillese said. “It was not mercy to harm or kill them.”

Wettlaufer was fired from her first job, at an Ontario hospital, after working while high on anti-anxiety medication that she admitted to stealing.

She killed her first victim in 2007 at the Caressant Care facility in Woodstock, 80 miles southwest of Toronto. By the time she was fired in 2014 for administering insulin to the wrong patient — not a victim — she had killed seven people and injured four others, often as the sole nurse working at night.

Caressant Care sent a termination form outlining several complaints to Ontario’s nursing regulator, but the regulator did not investigate. The nursing home dismissed Wettlaufer with $2,000 and a recommendation letter stating that she had left for personal reasons, in part to avoid a grievance from the nurses union.

Neither the nursing home nor the union had a comprehensive list of Wettlaufer’s disciplinary history, Gillese wrote.

Vicki McKenna, the president of the Ontario Nurses Association, said the union has been asking for more funding for decades.

Jim Lavelle, the president and owner of Caressant Care, said he would work with lawmakers and others to address the recommendations.

Wettlaufer would go on to work at Meadows Park in London, Ontario — where she killed another patient — and other facilities.

While incarcerated for her crimes, Wettlaufer told prison staff that she had harmed two other residents in long-term-care homes. Police investigated but did not file additional charges.

James Silcox was Wettlaufer’s first victim.

His son said Gillese did a “fantastic job,” but he was conflicted over her decision not to assign individual blame.

“The nurses union certainly has been running scared until today,” Daniel Silcox said. “They covered for Wettlaufer, and unfortunately, it blew up in their face.”

He said his father, who was 84 when he was killed, was a World War II veteran who never missed Sunday church.

“He always wanted to leave at the time of God’s choosing, and he didn’t do that,” Silcox said. “He left at the time of Wettlaufer’s choosing, and it breaks my heart.”