Issues raised in the NSW Coroners report into the fire at Quakers Hill Nursing Home
On 9 March 2015 the New South Wales (NSW) Coroners Court handed down its findings into the deaths of 14 residents at the Quakers Hill Nursing Home in November 2011. The report can be accessed at the State Coroners Court of NSWwebsite (
The NSW Coroner identified a wide range of issues arising from the tragedy and specifically recommended the Department of Social Services publish information on some of these issues. These issues cross all jurisdictional boundaries and include:
- employers ensuring they have exercised due diligence when employing people;
- ensuring that employers and staff are aware of the signs of drug dependency in staff;
- awareness of the mandatory reporting requirements for health professionals registered with the Australian Health Practitioner Regulation Agency (AHPRA);
- consider how Schedule 8 drugs are managed; and
- the importance of testing the emergency management plans within a facility.
While the NSW Coroner identified these issues within the context of residential aged care, aspects of these issues will be relevant for all providers of Commonwealth subsidised aged care services.
Further work will be undertaken over the coming months that will examine in some detail the Coroner’s report and where further learning can be gained. Aged care peak bodies and the Department will work collaboratively to understand issues and where needed, produce information to promote good practice.
- Scrutiny of employment records - Employers need to exercise due diligence
A critical lesson noted by the NSW Coroner was that:
“It is…as a matter of best of practice, incumbent on employers to check the bona fides of potential health professional employees by conducting reasonably thorough background checks.”
Good business practice would indicate that when a person applies for a position and has significant gaps in their employment history or absences from a particular field of work that an employer may wish to ask about these absences. Employers need to exercise an appropriate level of due diligence. On this point the NSW Coroner was firm.
“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.”
This was a reference to the concealed employment history of the staff member who, while being sentenced for murder and causing grievous bodily harm, admitted to starting the fire. This prevented the employer from contacting previous employers and allowed the known concerns over drug use to remain hidden.
In addition, Approved Providers are responsible for ensuring their staff have appropriate qualifications needed to perform their duties. Advice reminding Approved Providers about checking staff qualifications and registration was distributed to the sector via BIDS on 19December 2014. This information can be found on the DSS website (
- Recognising drug use
The NSW Coroner commented on drug use and reporting. This included the need to reasonably be able to detect if a staff member was under the influence of a drug and secondly the procedure for and requirement to report such behaviour. The NSW Coroner noted:
“...the desirability of nurses and health professionals receiving routine in-house training concerning the potential misuse of drugs by members of their professions, the signs of impairment due to drug misuse or dependency, and the procedures for reporting any concerns…”
It is important that employers and staff are able to recognise the signs or symptoms of drug dependancy and are able to act appropriately to intervene. The NSW Coroner provided a checklist in their report that may be useful for employers and staff to consider.
- AHPRA mandatory reporting requirements
The NSW Coroner further noted the need for administrators of nursing homes to:
“…develop and put into practice clear and simple standard operating procedures or protocols for the investigation and management of suspected cases of nurses and other health staff working while drug-intoxicated.”
Approved Providers are also reminded that for health practitioners who are registered with the Australian Health Practitioner Regulation Agency (AHPRA) there are mandatory reporting requirements. These reporting obligations apply to the employer as well as other registered health practitioners. Development of protocols would need to reflect this legal obligation and could work to address the hesitancy that staff may feel in taking action against a colleague.
Registered health practitioners and employers have a legal obligation to make a mandatory notification to AHPRA if they have formed a reasonable belief [1] that a registered health practitioner is practising their profession while intoxicated by alcohol or drugs.
Impairment from drugs can arise from the use of illicit drugs (those that have no legal use permitted in Australia) or legally available drugs (available by prescription) but which may be being misused or abused. It can also refer to the impairment from substances that are not controlled drugs, this includes alcohol and some over the counter medicines and substances.
Details on mandatory reporting can be found on the AHPRA website ( . Conduct that requires mandatory reporting includes practising while intoxicated, sexual misconduct, placing the public at risk of substantial harm due to an impairment, and placing the public at risk due to significant departure from accepted professional standards.
- Security of schedule 8 drugs
Drugs that have been classified by the Therapeutic Goods Administration (TGA) under thePoisons Standard as Schedule 8 drugs are also known as ‘controlled drugs’. These are substances which have a high potential for abuse and/or addiction. The requirements for storage, access to and reporting of suspected theft or missing Schedule 8 drugs are set by individual state and territory legislation.
Approved Providers are responsible for ensuring that they meet all relevant local requirements. Standard 2.7 of the Accreditation Standards states that in relation to medication management, care recipients’ medication is managed safely and correctly.
The NSW Coroner raised some concerns over the efficacy of the management practices for S8 drugs noting:
“To allow any staff member to have sole access to Schedule 8 drugs at night was very lax management practice.’”
A concern of the Coroner in this case appears to be the risk that allowing an individual unfettered access can pose. The Coroner suggested that the facility should have considered practices that required having two staff members present for opening of the S8 drug cabinet.
In addition to meeting the legislative requirements, Approved Providers are encouraged to consider further steps to mitigate the risks that unauthorised access, improper use, or theft of S8 drugs pose in their facilities. In considering risk mitigation, a facility will need to have regard to the care and services they are required to deliver and the staff they have available.
- Emergency evacuation training
The NSW Coroner noted a number of issues centred around the physical response to the fire and the subsequent evacuation. These issues highlight the importance of ensuring that training and education include both theory and practical elements.
Under the Aged Care Act 1997 and Quality of Care Principles 2014, Approved Providers of residential services have a responsibility to be prepared for emergencies. This includes having emergency risk management plans and protocols in place to protect the health, safety and wellbeing of care recipients. This is required under the Accreditation Standards, in particular Accreditation Standard 4.6, Fire, Security and Other Emergencies.
The NSW Coroner has noted that a practical exercise in evacuating buildings is conducted annually in NSW Health facilities and in their view, ought also be standard practice in nursing homes.
Approved Providers are asked to review their current preparedness for an emergency and if this includes a practical exercise or testing of their evacuation plan. A ‘full scale’ exercise may not always be practical but developing, testing and reviewing emergency plans is a continuous process. The Quakers Hill fire and associated response was complicated by a number of specific physical impediments, including the inability of beds to fit through some egress routes. Practical testing will allow these issues to be identified and corrected as needed.
Staff must be adequately trained in emergency procedures. Arrangements for information, training and instruction of workers should be set out in the emergency plan itself. Training may include practising evacuations, identifying assembly points, location of emergency equipment and first aid. A further aspect to consider is engagement with the local emergency services operating in the area both to draw on their expertise and to also allow collaborative preparation for emergency situations.
There are a variety of publically available resources that can assist in this area such as the Australian Emergency Management Handbook 4 – Evacuation Planning which can be accessed at
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[1]‘Reasonable belief’ is a term commonly used in legislation, including in criminal, consumer and administrative law. While it is not defined in the National Law, in general, a reasonable belief is a belief based on reasonable grounds.