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Coroner's Court NSW: Inquest into the Fire at Quaker's Hill Nursing Home

Mr. Roger Dean was hired to work as a nurse on the night shift at this nursing home.  He began employment on September 13, 2011.  He was hired on the basis of one interview and confirmation that he held a nursing certificate. His resume showed that he had worked at a cake shop since 2007.  It was later revealed that the shop was owned by his domestic partner.  (Why a registered nurse would spend four years working in a cake shop was never queried.)  His last experience working in aged care was listed as being in 2001-2002.  In fact, he had been employed in numerous aged care roles before applying to Quakers Hill, and as was later discovered, had difficulty at each of them.

11 September 2015 | By Dr Ken Byrne

No references were checked, and this was not part of the company’s hiring process.  A pre-employment medical was required but was not done.

After being hired it soon became apparent to staff who worked with Mr. Dean that he was a substance abuser and almost certainly an addict.

On November 17
th, when he anticipated he would be questioned about his theft of Schedule 8 medication, Mr. Dean set fire to several mattresses. The nursing home burned down and 14 residents were killed. (Several others died in hospital in the following weeks.)

Mr. Dean was sentenced to life in prison.

The following comments are excerpts from the Coroner’s Report.

It is difficult to imagine the terror and horror that the victims of this dreadful atrocity must have felt as they lay trapped choking on dark smoke with a fire blazing nearby. Family members have spoken for many of them. All were good decent people who had lived for others and who deserved so much better than this in the last stages of their lives.”

“….(as)  the nursing home was desperate to fill the vacancy for a night shift Registered Nurse, virtually nothing was done to check Mr Dean’s bona fides except to ensure that his registration was current.

There is clear evidence of incidents of concern in Roger Dean’s employment history prior to his recruitment at Quakers Hill Nursing Home.

It is, therefore, in my opinion, as a matter of best practice, incumbent on employers to check the bona fides of potential health professional employees by conducting reasonably thorough background checks
Not to conduct adequate background checks on new employees may constitute a serious failing on the part of a health service organisation to protect the public interest…..employers may be exposed to legal liability if they fail unreasonably to check out potential employees.”

This excerpt has been prepared by Dr. Ken Byrne, Director, SAFESELECT for instructional purposes.

The complete Coroner’s Report can be found at: