The report by the state Deputy Coroner into the fire at the Quaker's Hill nursing home in November, 2011 is scathing. The senior nurse on night duty started the fire that resulted in the death of eleven elderly and helpless patients, despite being the prime suspect in the theft of drugs from the drug cabinet for which he held the security key. Roger Dean subsequently admitted guilt and is now serving a life sentence.
The coroners report was critical of the depth of security investigation prior to Dean's engagement by the nursing home. He was terminated from a previous employment because of drug use and this went unrecognised when the nursing home was desperate to fill a night duty slot. As a consequence, Dean was the employee trusted with the access key to the drug room.
The enquiry also revealed that the nursing home was aware of a drug discrepancy and Dean was suspected of the theft, but he was not stood down and removed from the premises, and setting the fire was intended to cover his tracks and destroy incriminating records to cover his crime.
Another aspect of this enquiry is chilling. The nursing home was a modern, purpose built building and yet when emergency services commenced rescue attempts it was not possible to wheel beds and their occupants to safety - because of building defects. There were difficulties progressing through doors and a ramp exiting one block was too narrow to allow the passage of beds.
This raises the question of how this could be allowed to happen. A whole host of authorities are involved in the licensing of a nursing home and a strict protocol applies when it comes to the required safety measures that must be in place. How could a nursing home with access defects be granted approval to operate by both the local council and the Department of Health. Surely such premises must pass a safety inspection on building completion, and at the time of annual licensing renewal ?
The big question is - how many other nursing homes have similar, undetected problems that will only see the light of day when a tragedy similar to Quaker's Hill occurs ? As a result of this fire, all new nursing homes are required to have automatic sprinkler systems installed and existing nursing homes have a time frame which requires this fire safety measure. The burnt building was demolished and there is now a new nursing home on the site - with fire sprinklers - and it has been subjected to a name change.
The coroners report should certainly upgrade the level of security checks carried out on all staff recruited by nursing homes , but this is a case of shutting the gate after the horse has bolted. Treating the elderly requires the use of all manner of drugs and these include powerful pain killers - and that must be a huge attraction to anyone suffering a drug dependency. It is essential that the person who serves as the gatekeeper to this drug supply be above reproach, and that can only be ensured if the selection process involves the deepest security analysis.
It would also make sense if every nursing home in this state was subjected to an evacuation check by both council building inspectors and the Department of Health to ensure that there are no inward opening doors to halt the evacuation process and that all exitways are of the required width.
The only good thing about the Quakers Hill tragedy is that it revealed shortcomings that had gone undetected. Putting that knowledge to use should ensure there will not be a repeat !
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