The nurse behind the fatal Quakers Hill Nursing Home fire was allowed to keep working despite strong suspicions he stole hundreds of painkiller tablets, an inquest has heard.
Roger Dean was seen going in and out of the treatment room, where a medication cabinet was kept, while on night shift at the western Sydney home on November 16-17, 2011.
The next day he lit a fire there, which led to the death of 14 elderly residents.
Dean is serving life in prison after pleading guilty to 11 counts of murder.
An inquest into the tragedy has heard that an audit of the treatment room before the fire revealed about 230 tablets of the strong painkiller Endone were missing.
A registered nurse informed a manager and police were called on November 17.
A later review of CCTV footage and reports from staff revealed Dean had gone into the treatment room on several occasions and closed the door behind him.
Nurse Janette Mitchell, who worked at the Quakers Hill home for 26 years, confirmed it was unusual.
"Because we don't usually shut the door and there wouldn't have been any reason for him to be in the treatment room for extended periods of time," Ms Mitchell told the inquest on Tuesday.
Ms Mitchell told the Glebe Coroners Court she suspected Dean was involved in the missing medication.
However, she confirmed there were no discussions with a manager about Dean being suspended or sent home straight away.
Dean turned up for his night shift on November 17, 2011, and was given a key to the treatment room during a handover with Ms Mitchell.
However, Ms Mitchell said she felt she should not give him the key to the medication cabinet.
Another nurse, Deep Kunwar, told the inquest she informed Dean about the missing medication when he started his shift, and said she might have told him police were called.
The nurse said Dean focused on her incident report about the missing drugs and looked "shaky".
She said she was never told by other staff not to tell Dean about the missing medication.
The inquest continues.
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