Inquest into the deaths and fire at the Quakers Hills Nursing Home, Hambledon Road, Quakers Hill

Contributing factors

• deliberate arson by drug-dependent nurse Roger Dean
• poor employment screening and failure to check references
• lack of inter-agency communication regarding Dean's prior drug-affected conduct at St John of God Hospital
• failure to conduct pre-employment medical screening
• inadequate supervision of night-shift nursing staff
• failure to remove Dean from duty after medication theft discovered despite staff concerns
• lack of training for staff in recognising signs of drug dependency in colleagues
• absence of clear protocols for managing suspected staff misconduct
• inadequate security of Schedule 8 drugs (Dean left alone with access to drug cabinet)
• delay in police response to medication theft report
• fire spread facilitated by open door to ward 3
• design flaws including ramp at rear exit obstructing evacuation of bedridden patients
• absence of sprinkler system
• hydrant positioning non-compliant with Australian Standards
• staff not making direct '000' call to Fire and Rescue (relied only on automatic alarm)
• Fire Indicator Panel design allowed second fire to go initially undetected

Coroner's recommendations

1. NSW government provide funding for mobile data terminals in Fire and Rescue NSW vehicles
2. Fire and Rescue NSW develop digital database of pre-incident plans for major structural fires
3. Fire and Rescue NSW develop and disseminate 'lessons learned' e-learning package emphasising urgent escalation for structure fires with large occupancy, rescue of non-ambulant patients and patients attached to medical equipment, and management of hose lines jammed in fire doors
4. Fire and Rescue NSW and Department of Planning work together to address hose lines jamming in fire doors
5. Fire and Rescue NSW issue blocks/wedges to firefighters or task firefighter to keep advancing lines free when hose lines being advanced
6. Fire and Rescue NSW issue bulletin to aged care facilities identifying difficulties encountered and lessons learned, including urgent necessity for staff to make '000' calls, cross-check calls made, remove patients and close fire doors quickly, prioritise wheeling beds over dragging, keep passageways clear, account for medical equipment impediments in evacuation plans, keep fire exits clear, and conduct regular scenario-based practical training in removing non-ambulant patients
7. Fire and Rescue NSW consult on best means to advance hose lines beyond fire doors without compromising fire compartment integrity or jamming lines
8. AHPRA consider requiring employers notify when health professional commences or leaves employment
9. AHPRA consider including employment details in registration database (employer name and contact details, employment period, notifications made to AHPRA)
10. NSW Minister for Health refer case to Poisons Advisory Committee to consider amending Poisons and Therapeutic Goods Regulation 2008 to improve Schedule 8 drug security in nursing homes
11. NSW Minister for Health consider requiring nursing homes by regulation to use identification armbands on all patients at all times unless overriding medical reasons exist
12. Commonwealth Department of Social Services and NSW Department of Aged Care, Disability and Home Care publish 'lessons learned' case study document addressing signs of drug-dependency in staff, mandatory reporting requirements, scrutiny of employment records with gaps, Schedule 8 drug security, and emergency evacuation training