It’s 5am the 18th November 2011. A fire breaks out at the Quakers Hill nursing home 40km west of Sydney NSW Australia. 14 of the 81 residents of the home would die in the fire or in the period soon after. Roger Kingsley Dean, a registered nurse employed at the home, would ultimately pleaded guilty to, and was convicted in respect of, eleven counts of murder by way of reckless indifference to human life. On this episode, we will find out what went wrong and how this horrific event could have been avoided.