CARERS responsible for double-checking dangerous medication at a Legana nursing home often had trouble reading, a Launceston inquest has heard.
Tamar Park nursing home policy directed that dangerous medication, like morphine, be double-checked before being given to residents.
But yesterday the inquest into the death of a Tamar Park resident heard some of the staff doing the checking had poor numeracy and literacy skills.
Palliative care patient Stanley Valentine Whiley, 67, died at the facility in March 2010 after being mistakenly injected with 10 times the intended dose of morphine.
It is unclear what part the overdose may have played in the death.
On her second shift as a registered nurse, an unsupervised Julie Lord drew 25 milligrams of morphine into a syringe instead of Mr Whiley's intended dosage of 2.5 milligrams.
She did this in front of an extended care assistant but neither spotted the error.
Registered nurses can administer such drugs only in the company of a ``responsible person'', which at Tamar Park included carers.
In an affidavit, former Tamar Park manager Sandra Renshaw said she noticed carers had trouble working out food rations, ``then they just guessed''.
Mrs Renshaw said she told Julie Reed, an executive director with Tamar Park's parent company Aged Care Services, who said it was acceptable as long as staff passed competency tests.
The inquest heard from Mr Whiley's doctor, who expressed concern that carers were deemed ``responsible people'' at Tamar Park.
Dr Lee Jones said it was becoming common for inexperienced nurses to administer dangerous medication.
``Obviously this is a cost-cutting exercise and it is a concern . . . I hope this practice will not lead to more mistakes like this,'' he said.
Dr Jones said that after deeming Mr Whiley a palliative care patient on March 1, he thought he would die within a week.
Consultant physician Dr Ross Ulman said it was probable the morphine overdose had nothing to do with Mr Whiley's death, given his heart disease, previous cardiac arrest and recent strokes.
He said Mrs Lord should have had better support that day.
``The victim in this matter is [Mrs] Lord . . . a victim of a system breakdown not of her making,'' he said.
``I think the breakdown is at the nursing home from the beginning of her employment as a registered nurse.''
Mrs Lord was given a one-hour medication-management competency test by Tamar Park, which did not include schedule-8 drugs like morphine, the inquest heard.
Dr Margaret Winbolt, a senior research fellow at La Trobe University, agreed Mrs Lord faced a stressful situation as the only nurse looking after 38 residents.
She said it was normal for graduate nurses to be looking after five or six patients but always in the company of other registered nurses.
But in a report she said she would have expected Mrs Lord to ``rigorously check the labels on the (morphine) ampoules''.
She also agreed Tamar Park had a system sufficient to guard against dosage mistakes.
The inquest heard the nursing home had changed its policy so new nurses spent their first five shifts being ``buddied'' by another nurse.
Detective Constable Matt Knight gave evidence that police were concerned some of Mr Whiley's medical records might be destroyed by Tamar Park when an investigation into the death started.
The inquest before coroner Rod Chandler continues today.