CHAPTER THREE: What Did We Miss?
Nursing assistant Sidonia Thompson was desperate. “If you can hear me, please don’t send Luneta home,” she called out, hoping her voice would carry across the room to where supervisor, Luneta Mateo, was speaking hurriedly into the phone. “Or send somebody… I am scared for all of us.”
As Quakers Hill Nursing Home’s clinical manager, Luneta was responsible for the supervision of the facility’s staff – and in this moment, the staff were terrified. Sidonia was one of the assistants-in-nursing (AIN) for that night’s shift and was only saying what her three co-workers were thinking: Please don’t leave us alone, not with him. She stood, hovering, while Luneta finished the call with their boss, Zuzana Stofan. But Zuzana’s orders were clear.
Luneta Mateo walked out the front door of Quakers Hill Nursing Home in the early hours of November 18, 2011. In the moments before she left, she handed Roger Dean a blue lanyard, attached to which was a special key. As the registered nurse in charge, Dean would be the only member of staff with access to the Schedule 8 cabinet, where the facility’s drugs of addiction were stored.
Roger Dean was a new employee. If anyone had looked at the 35-year-old’s resume closely, they may have noticed gaps in his work history. If anyone had called his listed references, they may have realised that all three of them were more than 10 years old. If anyone had insisted that Dean undergo the protocol-mandated medical screening, they may have been informed of his litany of prescriptions for anti-depressants and major tranquilisers.
No-one did. At 10.30pm on September 13, 2011, he clocked in for his first shift as registered nurse at Quakers Hill Nursing Home.
Two months later, and exactly one hour after Luneta Mateo exited the building, Roger Dean lit the first of two fires that would take the lives of 13 elderly men and women.
Emergency service workers survey the damage left by the fire, courtesy Channel 9
“You go look at all these nursing homes… make sure they smell nice, they’ve got activities,” Donna Austin is explaining to WSFM. “You go ‘no’, ‘no’, ‘no’, ‘no’.
“And then we stumble on Quakers Hill. It was big, it was open, they had an outdoor area, they could take them out.”
Lorraine Osland agrees, as do Sue Webeck and Haley De Martin. Quakers Hill Nursing Home was clean and well laid-out; the staff were friendly and, for the most part, helpful. The decision to put a parent in a nursing home is not a simple one – Donna still considers it “the hardest thing I ever could have done” – but Quakers Hill eased the feelings of guilt and upset, if only a little. It seemed like the right place. And, on the surface it was. So what went wrong?
The coroner’s report makes for uncomfortable reading; it is stark, unemotional and blunt. It lists how a devastating, murderous act was set in motion. It’s harsh and harrowing, but clear.
This is what we missed.
A police rescue officer wipes his eye amid the chaos
The nursing home was desperate to fill the vacancy for a registered nurse to cover night shifts. As a result, virtually nothing was done to check Roger Dean’s bona fides, except to ensure that his registration was current. For this reason, no-one realised that, less than two weeks prior to joining the staff of Quakers Hill Nursing Home, Dean had terminated his employment with St John of God Hospital, where he had been found drug-affected at work.
And while numerous staff members at Quakers Hill shared fears Roger Dean was under the influence of drugs during his shifts – mentioning “sightings of white substances in the corners of his mouth; occasions on which he appeared dishevelled; erratic and other behaviours” – few reported them to management. What concerns were passed on seem to have been largely ignored.
CCTV footage shows Roger Dean entering the Schedule 8 drug cabinet numerous times, courtesy Fairfax
On the afternoon of November 17, 2011, a routine audit of the Schedule 8 drug cabinet indicated that 237 tablets of Endone and one tablet of Kapanol, both opioid medications, were found to be missing. Both Luneta Mateo and Zuzana Stofan firmly suspected Roger Dean of the theft; a review of CCTV footage from the night before showed him entering the locked room 36 times over the course of his shift. They called the police, who came to investigate at about 11pm that evening. Their presence appears to have rattled a “very restless… anxious” Dean.
Less than 20 minutes after arriving at the nursing home, however, the attending officers were called to an emergency and left. Luneta waited until 3.43am for their return at which point, despite her misgivings, she left for the night. That meant Roger Dean was once again unsupervised, and once again in the possession of the Schedule 8 cabinet key.
That’s the sticking point for Haley De Martin. “He shouldn’t have even been there. They suspected him of stealing drugs, but they let him stay on shift.
“I’ve worked in bars… If I was caught stealing a stubby, it’s instant dismissal. But they suspected this man, and they let him stay there, to finish his shift. The mind boggles.”
At 4.50am, the same police officers rang the nursing home. In the absence of a manager on scene, they decided to postpone their return visit until the morning.
At 4.53am, the fire alarms screamed to life.
A fire officer extinguishes flames from the roof of the nursing home, courtesy Channel 9
That alarm – indicating Dean’s first fire in an empty bed in ward 19 of the facility’s A2 wing – triggered an automatic alert to Schofields and Blacktown Fire Stations. While their response was, as always, seriously undertaken, both pumps reasonably expected to be treating a false alarm. That assumption was only exacerbated by the fact that no member of staff rang ‘000’. Had even one emergency call been made, the response by Fire and Rescue would have been immediately escalated.
As it was, only two fire engines were on scene for the first 24 minutes of the fire. That was 10 fire fighters for 81 elderly residents, men and women who were bed-bound, suffering from Alzheimer’s and dementia, who were confused and unable to save themselves. There wasn’t a fraction of the manpower required to extinguish the fire; instead, it became very obvious, very quickly, that Fire and Rescue’s priority was that of retrieving bodies.
An elderly resident is evacuated by emergency services
“When you hear all the mistakes, and the errors, you think, oh my god, this could have so been avoided,” Donna Austin says, shaking her head. It’s not hard to see why; the coroner’s report underlines each flaw, each miscalculation.
The “fail-safe” fire doors trapped and jammed the hoses.
The purpose-built fire hydrant did not “provide sufficient coverage to the required areas within the building.”
The fire roared into supposedly heat-resistant roof space, sending burning ceiling materials and beams crashing into the rooms below.
The emergency ramp – which was later found to be absent from building plans – incorporated a 90° angle that “did not permit beds to be wheeled down the ramp, and away from the building.” Heavy, unwieldy trolleys piled up in the corridors, jamming the hallway and blocking the escape.
The extreme heat – estimated to be in excess of 1000°C – made search and rescue a slow and arduous process; officers entered rooms, on their hands and knees, feeling along the perimeter of the walls, as good as blind. When they bumped into hospital beds, they reached up, feeling for a body. One by one, fire fighters pulled and dragged people to safety.
And one by one, they turned and ran straight back into the flames.
Images of what is left of the beds in ward 19 show the sheer force of the fire
The horrific and startling events of November 18, 2011 prompted the coroner, Hugh Dillon, to make a long list of recommendations. Some, like the proposal to implement regulation requiring nursing home patients to wear identification bands, have been ignored. Others, like the suggestion that Fire and Rescue NSW distribute an “e-learning package”, detailing everything that the Quakers Hill Nursing Home fire brought to emergency services’ attention, have been carried out.
“Fire fighters across the state are being trained in care facilities and the training of the movement in care facilities,” Station Officer Brett Johnson tells WSFM. “Different techniques that we can use in removing people from their beds, out to an evacuation point.
“All fire fighters have learned from this experience.”
Perhaps the biggest consequence of the fire has been the introduction of new legislation requiring the installation of fire sprinklers in residential aged care facilities in NSW. The ruling followed a startling video released by Fire and Rescue NSW, which demonstrated the dramatic difference smoke-triggered sprinklers can truly make in a situation like the Quakers Hill Nursing Home fire.
It’s nearly impossible to escape the fact that, had the aged care facility been outfitted with sprinklers – the same sprinklers that dot the ceilings of cinemas and shopping centres – the outcome would have been significantly, if not completely, different
Footage released by NSW Fire & Rescue show the difference sprinklers would have made
“We could have dealt with their deaths if it had happened naturally, if we’d gotten a phone call in the middle of the night,” Lorraine says. “But the way it went down was horrific. We have a problem with what happened, why it happened. This is [what] we find hard to understand.”
That’s the part Haley can’t accept.
“It just shouldn’t have happened,” she whispers. “And when you think of that, you don’t get any closure.”
The coroner’s report eventually concludes. “It is difficult to imagine the terror and horror that the victims of this dreadful atrocity must have felt,” Mr Dillon writes, “as they lay trapped, choking on dark smoke with a fire blazing nearby. 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.
“I hope… that this tragedy will result in lessons being learned and implemented, that will save other vulnerable people from harm and death in future years.”
And that is something the Quakers Hill families hope too.