When drug-addicted nurse Roger Dean applied for a job at the Quakers Hill nursing home in September 2011 his CV stated that he had spent the past four years working at the local Cheesecake Shop.
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His only two referees were the shop's manager, who was also Deans' boyfriend at the time, and a supervisor from a nursing job some 14 years earlier.
Without calling either referee, the nursing home gave Dean the job, and within weeks had made him the sole registered nurse during the night shift, giving him virtually unfettered access to the home's supply of opioid painkillers.
Two months later, the NSW Coroner's Court has heard, Dean set fire to the home while residents slept in their beds, murdering 11 of them.
As Deputy NSW Coroner Hugh Dillon began a coronial inquiry into the 11 deaths and deaths of three other residents soon after, it was revealed that, had the home's management checked into Dean's work history they might have discovered a series of disturbing incidents from his past.
While employed at St John of God Hospital in 2011, Dean had presented to work with slurred speech, his clothing dishevelled, and with white spittle around his mouth.
He was immediately suspended and sent home.
But Dean claimed later that his unusual behaviour was the result of a change in his medication for bi-polar disorder. This was supported by a letter from the nurse's doctor, Dr Mohamad Sadiq Asar, indicating that his medication had changed.
However, it later emerged that Dr Asar had never formally diagnosed Dean with bi-polar. Despite this, the inquest heard, he had prescribed the nurse with powerful prescription drugs including pain killers and anti-depressants, often at the nurse's own request.
But this wasn't the first time Dean's behaviour had raised serious concern in a NSW hospital.
The inquest heard that four years earlier, while Dean was working at St George Hospital, he was involved in a dispute with his supervisor over patient notes in which he accused her of being patronising and condescending.
Soon after the incident, the woman's car was found with screws in the tyres and paint poured over the roof.
Dean resigned from the hospital before an investigation took place.
Neither of these incidents, the inquest heard, was reported to a disciplinary or registered body, and just months later Dean turned up to the Quakers Hill home where he was employed soon after.
"He was effectively employed without anyone interviewing anyone on the CV and, insofar as the CV was concerned, not having had aged care experience since 1997," Counsel assisting the inquiry Kristina Stern, SC, said in her opening address.
"That someone with that history could find himself working in a place where he had access to schedule 8 drugs is obviously of some concern," she said.
"There is also clearly a very real public interest concern in someone with an addiction being employed in a position of responsibility over vulnerable elderly patients."
Ms Stern said the home's screening of prospective employees and the lack of any easily accessible report about the killer's past would be among the issues examined during the inquest.
The hearing continues.
