25th Annual Medico-Legal Congress

25-26 February 2016

Lessons Learned from the

Quakers Hill Coronial Inquest

Presented by:

Zara OfficerSpecial counsel

(02) 9390 8427

zara.officer@holmanwebb.com.au4363331

Quakers Hill Fire

Quakers Hill Fire

Lessons Learned

Recruitment and

background/reference checking

potential staff

Dealing with staff who are

impaired with substance abuse

and Schedule 8 limitations

Mandatory reporting

Emergency evacuation procedures

Findings of Deputy State Coroner, HCB

Dillon delivered 9 March 2015

Combined inquest into the fire and death of 14 residents

Fire lit by Roger Dean, registered nurse

Convicted of 11 counts of murder by reckless

indifference to human life

Convicted of recklessly causing grievous bodily harm to

8 people

Life imprisonment without parole

The Fire

The Fire

Employment Background of Roger Dean

Born 1976

Registered nurse 1996

Employed at St. George Hospital

& Community Health

Services 2002 to 2007

Employed at St. John of God

Hospital, July 2007 to September

2011

28 June 2011 found to be drug

affected at work at St John of God

Application for Employment at

Quakers Hill Nursing Home

Provided CV to Quakers Hill Nursing Home prior to 6

September 2011

Omissions in CV

No mention of employment at St. John of God Hospital

2007-2011

Old references provided, the most recent from Year 2000

Appointment to Quakers Hill Nursing

Home

Appointed soon after single interview

References not checked

Employee engagement checklist included obtain police

check, but not reference check

Checklist completed 7 September 2011

No pre-employment medical screen done

Attended in-service staff training – 6 September 2011

Commenced nightshift - 13 September 2011

Formal contract of employment – 20 September 2011

Nightshift 16-17 November 2011

AIN observed Roger Dean in treatment room for a large

amount of time with doors closed

CCTV footage showed Roger Dean going in 36 times

Spent approx 2 hours of the shift in treatment room

Missing – 237 tablets Endone; one tablet Kapanol

Roger Dean suspected of theft, not suspended from duty

Destruction of Evidence

Latham J criminal sentence finding –

Intention to light fire was either to:

deflect management from further inquiring into the theft and/or

destroy the treatment room evidence

Abuse of Prescription Medication and

Psychiatric Issues

Search warrant 21 November 2011 – 203 Endone

tablets, 28 part Endone tablets, Kapanol, MS Contin,

Xanax, 20 prescriptions

Medical records evidenced “doctor shopping” – seen by

10 different GP’s April-November 2011

Forensic psychiatric in criminal trial diagnosed

polysubstance abuse, adjustment disorder, and cluster B

personality disorder with narcissistic and histrionic

features

Nursing Staff Concerns about

Roger Dean

On occasions before the fire:

white substance in corners of mouth

waking patients in middle of night to give Endone when they did not

request it

dishevelled appearance, shirt not buttoned to match the holes

performance issues

suspicions of substitution of pain medications with Panadol or No-Doze

patient observed to be in pain despite records showing pain medication

was administered

Missed Opportunities

St John of God Hospital episode in June 2011

No report made under s.142(1) National Law (cf s.117A

Health Services Act, for public hospital employees)

Failure by Quakers Hill to check with previous employers

Failure to follow up staff reports of concerning incidents

Staff not trained in detecting signs of drug intoxication or

addiction in professional colleagues

Staff Training and Development of

Protocols for Mandatory Reporting

In-house training on potential misuse of drugs by

colleagues

Training in signs of impairment or intoxication due to

drug use or dependency

Education as to responsibilities for mandatory reporting

under the National Law (s.140, s.142)

Establish operating procedures and protocols for

investigation and management of staff suspected of

working while drug intoxicated

Immediate suspension

Management of Drug Affected Health

Professionals

Education on the signs of impairment due to drug misuse

Signs and symptoms – physical signs – behaviour

changes

Clustering of signs

Reporting suspected cases of drug abuse

Management of Drug Affected Health

Professionals

To encourage staff to report, emphasise:

The primacy of the interests of vulnerable patients

The need to help the affected health professional

Their lack of discretion in the matter – mandatory

reporting

Send an apparently drug affected person or suspected

thief away from the workplace

Pre-Employment Screening

Applicant interviews

Tests to confirm general ability,

aptitude and personality

Medical checks

Reference and background checks

In the Interview

It is appropriate to ask:

How long did they spend in

previous jobs?

Recruitment source – who

were they referred by?

Do they have accurate

perceptions of what is

involved in the role?

Reasons for seeking the role?

After the Interview

Reference check prior to any offer

Qualification check – documentary evidence

One/possibly two, competency based interviews by the

line manager/HR

Medical assessment

Obtain consent from the candidate before conducting

searches (include on an application form or request

following first interview).

Searches After Interview. . . continued

Background checks such as police/criminal checks

AHPRA enquiries with respect to conditions on

registration or impairment

NSW service check register – Section 133C Health

Services Act allows a public health organisation to share

or exchange appointment information about a health

practitioner with a private facility licensee registered

under the Private Health Facilities Act 2007 (NSW),

subject to conditions

Section 133C Health Services Act 1997

(NSW)

133C Sharing or exchange of information about health

practitioner appointments

(1) Public health organisation may share or exchange appointment information about a health practitioner with a private health facility licensee if a public health organisation:

(a) reasonably believes that the health practitioner practises at the private health facility, and(b) reasonably considers that the disclosure of that information to the licensee is necessary because it raises serious concerns about the safety of patients

(2) Information is appointment information about a health practitioner for the purposes of this section if:

(a) the health practitioner practises (or formerly practised) at a hospital or health institution of the public organisation (whether under a service contract or otherwise), and(b) the information relates to the variation, suspension or termination by the public health organisation of clinical privileges of the health practitioner

Recommendations Concerning AHPRA

That AHPRA consider requiring employers to notify it when a

health professional falling under the agency’s jurisdiction

commences work and when he or she leaves that

employment. Any regulatory changes necessary be given

urgent consideration.

That AHPRA consider including employment details in its

registration database. Include name, contact details of

employer, period of employment, any notifications made to

AHPRA concerning the employee. Any regulatory changes

necessary be given urgent consideration.

Emergency Evacuation Procedures

Emergency Evacuation Procedures

Recommendations for Emergency

Evacuation Procedures

Use “000” instead of relying on automatic systems

Remove non-ambulant patients in beds or wheelchairs

preferably or alternative dragging methods

Passageways kept clear as far as reasonably practicable

Fire evacuation plan take into account impediments to

rescuing non-ambulant patients – connections to medical

equipment – make specific provision addressing those

challenges

Fire exits and doors kept clear of obstructions

Implement regular scenario based practical training including

practicing urgent removal of non-ambulant patients or

residents

Conclusion – Ongoing Issues

The incidental question of

doctor shopping

Robustness or otherwise of

mandatory reporting regime

Issue of drug dependence in

health professionals, access to

drugs

Practical procedures for

handling S8 drugs

Questions