NSW Deputy State Coroner Hugh Dillon urgently recommends the Australian Health Professional Regulation Agency (AHPRA) be notified when an employee commences work and when they leave that employment plus any notifications made to AHPRA concerning that employee.

This arises out of the fact that the written references for the nurse that lit the fire that killed 14 residents, Roger Dean, when applied for the job were 11 years old. He gave details of referees but they had not worked with him for at least four years and were not in fact contacted. His last nursing position was not given and therefore not checked. He had a questionable time at that hospital in relation to erratic behavior and possible drug use.

His most up to date reference was from the local cheesecake shop that was owned by his flat mate.
Domain Principal (now Opal Aged Care), the operator, had HR systems for nurses that required a police check and a medical screen but no CV check. They did the police check, no CV check and no medical screen.

The event that led to the fire was the discovery by a staff member of 237 tablets of Endone and one tablet of Kapanol missing at 8.30pm. She reported it to mangers and the police were called, who arrived at midnight but were called away to an emergency.

The staff subsequently watched Dean on CCTV coming out of the room acting suspiciously. He then locked himself in a storage room up to about 4.30am when he lit two fires.
What hasn’t been widely reported is that Dean had been studying law, and had just one subject to complete to graduate.

The drug conviction would have impacted on his law career.

The question the sector is asking is whether an extreme case such as this requires another round of regulation – such as mandatory employment record reporting.

Such records are almost inevitable in our opinion as we move in to the CDC world where increasingly frail clients will be staying at home longer and identifying the careers they wish to invite into their homes.