AGED CARE Alert: Increased regulation and improved processes – lessons learnt from the Quakers Hill Nursing Home fire

26 March 2015


The findings of Deputy State Coroner Dillon into the fire at Quakers Hill Nursing Home (Facility) deliberately lit by a rogue registered nurse, Roger Dean, were released on 9 March 2015.The findings have been widely reported and in this alert we focus on the likely areas for regulatory reform.

As well as making findings regarding the cause of death of the 14 residents that were the subject of the inquiry, the Coroner made a number of recommendations for regulatory reform that, if implemented would impact both aged care facilities and hospitals. While coronial recommendations aren’t binding, in such a high profile case, authorities are likely to pay close attention to them.

The Coroner highlighted four potential areas for regulatory reform:

  • that employers be required to notify the Australian Health Practitioner Regulation Agency (AHPRA) when a health professional falling under its jurisdiction commences or leaves its employment, and these details be included in a database maintained by AHPRA;
  • that AHPRA should consider whether the mandatory reporting regime should be expanded to cover health practitioners who have mental health issues (regardless of whether they have an impact on the individual’s practice);
  • that residents of aged care facilities be required to wear identifying armbands at all times; and
  • that consideration be given to whether regulations should be amended to improve the security of Schedule 8 drugs in aged care facilities.

These are discussed further below.

1. Provision of employment information to AHPRA

The Coroner recommended that employers be required to provide information to AHPRA to allow it to establish a centralised database of the employment history of each health practitioner.

This recommendation is aimed at preventing the failure of the Facility to identify gaps in Mr Dean’s resume, which meant that issues with his previous employer were not discovered when he commenced employment at the Facility. The Coroner referred to the Facility’s failure to conduct pre-employment checks as a “critical lesson” to be drawn from the disaster. If Mr Dean’s employment history was maintained by AHPRA and able to be accessed by potential employers, he would have been unable to conceal the gaps in his employment history.

However, whether having verified employment history for health professionals justifies the large amount of work involved in collecting and retaining this information is not immediately apparent. Indeed, it is not clear whether having this information would have alerted the Facility to Mr Dean’s drug dependency. As the Coroner recognised, references from previous employers are notoriously variable in quality and can even be misleading.

2. Mandatory reporting

The Coroner raised the issue of the mandatory reporting regime and how it had failed to expose Mr Dean. It came to light that while Mr Dean’s previous employer had investigated him for being drug affected at work, he had attributed his behaviour to the side effects of recent changes to his medication prescribed to him for bipolar disorder.  The Coroner stated that Mr Dean’s explanation meant that his previous employer was reluctant to make a notification to AHPRA due to the adverse consequences that would flow to Mr Dean if a notification was made.

The Coroner identified that such a scenario was part of the difficulties in the ‘real world’ application of the mandatory reporting regime. The Coroner questioned whether mandatory reporting needs to be expanded to include situations in which the health practitioner is being treated for mental illnesses or with Schedule 8 medications over a lengthy period.

As the mandatory reporting regime already requires notification where a health practitioner has an impairment (such as a mental illness) which places the public at risk of substantial harm, the Coroner must be suggesting that AHPRA be notified of health practitioners who have mental illnesses, regardless of the impact it has on the individual’s practice. We consider that this may unfairly target capable practitioners who have a mental illness that is treatable, and which does not impact on competent practice. The Coroner wisely deferred to AHPRA’s expertise and jurisdiction on this complex issue.

Mandatory reporting is a relatively recent regime, having been introduced in 2009. It has been subject to some amendments since. The Health Alert we did on the recent amendments to the regime in NSW (which are yet to commence) can be found here.

3. Armbands for residents

The Coroner recommended that operators provide residents at aged care facilities with identification armbands to be worn at all times unless there are overriding medical reasons not to do so. While there is no doubt this would make identification of residents in emergency situations easier, it may not be consistent with many operators desire to provide bespoke, home like environments for their clients.

4. Improved security of Schedule 8 Drugs

The Coroner criticised the fact that one staff member had sole access to the Schedule 8 cupboard at night. While acknowledging that the Poisons and Therapeutic Good Act 1966 and Regulations 2008 (NSW) did require two nurses to be present whenever the Schedule 8 cabinet was opened, the Coroner noted that the effectiveness of the regulations relied on sound management practice. In this context the Coroner recommended consideration of whether greater regulation is necessary for the use of Schedule 8 drugs in nursing homes.

While the regulatory reform outlined above will be subject to debate, other recommendations are more straightforward. For example, it is hard to argue with the Coroner’s recommendation for an e-learning package and a lessons learned case study document to be disseminated to staff at all aged care facilities setting out lessons learned from the incident, including:

  • the need for immediate escalation of the alarm level for structural fires involving buildings occupied by large numbers of people. In this incident, the staff relied on the automatic call that was put out to Fire and Rescue following the fire alarm being triggered. Due to the high number of false alarms from automatic calls, Fire and Rescue do not sent out a large number of resources to respond to them. If a separate call had been put into ‘000’ providing details of the fire, Fire and Rescue would have been able to allocate additional resources to fight the fire more rapidly;
  • the need to train staff in rescue techniques, especially the rescue of non-ambulant patients and patients attached to medical equipment. The Coroner specifically referred to the benefits of practical training exercises, and that in his view practical training in the removal of patients in the case of emergencies should be standard practice;
  • how to recognise signs of drug-dependency in nursing staff and other health professionals, and the desirability of routine in-house training concerning potential misuse of drugs; and
  • how to manage hose lines jammed in fire doors.

Implementation of training and the dissemination of information on lessons learned will ensure, regardless of whether the regulatory reforms are implemented, the time and energy that has been devoted to investigating this tragedy will be used to improve the standards and processes of aged care facilities.

Written by:
Lucinda Smith | Partner | +61 2 9020 5748 |
Catherine Rosero | Senior Associate | +61 2 8248 5873 |
Alexandra Adams | Lawyer | +61 2 8248 3466 |