A registered nurse with a chequered work history and hankering for prescription drugs secured a job at a Sydney nursing home he later set on fire without any reference checks, an inquest has heard.
Roger Dean is serving life in prison after pleading guilty to 11 counts of murder following a fire at the Quakers Hill Nursing Home in November 2011.
Fourteen nursing home residents died following the blaze.
An inquest into the blaze and subsequent deaths has detailed Dean's questionable work history and substance abuse leading up to the fire.
Dean managed to land a nurse in charge role at the aged care facility in September 2011 despite his resume detailing his most recent employment as at a cheesecake shop.
Counsel assisting Kristina Stern SC told the Glebe Coroners Court that Dean was suspended from his job at another hospital earlier in 2011 due to suspicions he was drug affected at work.
A patient at St John of God hospital found Dean in the medication room and claimed he was frothing at the mouth and couldn't administer her medication, the inquest heard on Monday.
The inquest also heard Dean, while working at another Sydney hospital, was suspected of putting screws into the tyres of a supervisor's car and throwing paint on the vehicle.
But neither this nor Dean's suspected prescription drug abuse on the job was made known to the Quakers Hill Nursing Home, the inquest heard.
Dean was employed on the basis of a brief CV, which didn't mention his job at St John of God hospital and seriously out of date references, Ms Stern said.
There was no evidence the nursing home checked the references, she added.
Ms Stern said Dean also regularly sourced prescription drugs from various GPs before the fire.
The fact someone with that history could find himself in sole charge of a medication room at the nursing home was concerning, Ms Stern said.
While on night shift on November 16-17, 2011, staff noticed Dean spending a lot of time in the treatment room on his own with the door shut.
Ms Stern said an audit of the medication later found hundreds of missing Endone tablets.
One staff member feared for her colleagues if left alone with Dean, the inquest heard.
Just before 5am on November 18, Dean used a colleague's cigarette lighter to light a bed sheet on fire in two separate rooms at the nursing home.
Ms Stern said Dean initially admitted to police lighting the fires but denied stealing medication.
Elly Valkay, daughter of nursing home fire victim Neeltje Valkay, said she was surprised to hear Dean's references were not checked before he was employed at the nursing home.
"Its a bit depressing to know that came out now and not before," she said outside court.
"That's the question we have to ask why weren't these checks made..."
The inquest continues.
