The signs were there.

From the white froth around the corners of Roger Dean’s mouth to his noticeable lingering in the drug storeroom.

And even before he was employed as a registered nurse at Quakers Hill Nursing home in 2011, there were hints that something was amiss.

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The references in his CV were seriously out-of-date and he left out any mention of his previous nursing position at a Sydney facility.

If he did include it, a check with his former employer might have revealed Dean was suspended after he was drug-affected at work.

But his work credentials went unchecked and on November 18, 2011, after learning police were poised to investigate him for stealing prescription drugs at the nursing home, he set the place on fire.

An inquest into the fatal blaze had also detailed evidence of Dean’s suspected abuse of prescription drugs.

Dean, 38, is serving life in prison for the murder of 11 people who died in the fire.

Donna Austin holds a picture of herself with her mother, who died in the nursing home fire. Photo: AAP

Following a long and often emotional inquest, Deputy State Coroner Hugh Dillon on Monday handed down the lessons learned from one of the worst fires in NSW history.

Among them is the need for employers to check the employment histories of prospective staff who will have access to drugs, including opioids.

Mr Dillon also recommended the national regulator – Australian Health Professional Regulation Agency (AHPRA)- consider keeping such records on its database.

He has also called for authorities to consider improving security around addictive prescription drugs at nursing homes.

However, supporters of the elderly residents who died as a result of the blaze appeared underwhelmed.

“I don’t know what to think, but at the end of the day I am just disappointed with what I heard,” Donna Austin, whose mother Alma Smith died, said outside the NSW Coroner’s Court.

Family and friends attacked the company behind the nursing home – formerly Domain Principal Group but now Opal Aged Care – for not showing up to the findings.

“They were not in this courtroom today to say ‘we are sorry’,” one of the victim’s friends Linda Morrow said.

“… believe you me, Domain, this is not over.”

A spokeswoman for Opal Aged Care said the company had legal representatives in court.

Mr Dillon found Dean, who had been doctor shopping for years, lit two fires at the nursing home with 88 elderly residents inside to try to destroy evidence of his drug taking.

“But he lit the fires knowing that he was placing lives at risk,” he said.

Mr Dillon paid tribute to the “good, decent people” who died.

“At least it can be said that they are now at peace,” he said.

The deputy state coroner also found design flaws at the nursing home impeded the evacuation.

Mr Dillon handed down a raft of recommendations for Fire and Rescue NSW, including addressing the issue of hoses being jammed in doors.

-AAP