A FORMER Legana nursing home manager faced tough questioning on the final day of Launceston inquest into the death of a palliative care patient.
Stanley Valentine Whiley, 67, died at Tamar Park nursing home in March 2010.
On the night he died, Mr Whiley, who also had heart disease and had suffered a recent stroke, was given an overdose of morphine by inexperienced nurse Julie Lord.
Experts have been unable to say if the morphine was a definite contributing factor to his death.
Yesterday, Sandra Renshaw was asked why she placed Ms Lord in charge of Tamar Park that day.
``Why didn't you stay for some or all of her first shift as a registered nurse when you'd put her in charge of a facility with 37 patients, one of whom is in palliative care?'' asked Ms Lord's lawyer, Greg Barns.
``I don't know,'' Ms Renshaw said.
``Do you think you should have in hindsight?'' Mr Barns said.
``After today, yes indeed, but I thought that I'd spent enough time with Julie and walked her through the role,'' Ms Renshaw said.
``There has to be a day when someone is left by themselves and I hoped and planned (on) this day that I had covered most of the contingencies for her.''
It also emerged that Mr Whiley's death was not immediately reported to the coroner as is required in cases of sudden death.
Ms Renshaw said she had trouble contacting her boss, Julie Reed, at Aged Care Services, which owns Tamar Park, and a doctor because it was a long weekend.
At times, the retired Ms Renshaw, who'd been a registered nurse for nearly 40 years, struggled under questioning and her answers were often inconsistent with an affidavit she'd given just after Mr Whiley's death.
During her eight months at Tamar Park, she said she met staff responsible for checking medication measurements who couldn't count and others who tried to receive benefits from residents.
She left Tamar Park following her probation period feeling ``very aware I was not able to do the job properly and safely''.
Ms Reed, executive director of Aged Care Services, said what occurred in the lead-up to Mr Whiley's death was an ``aberration''.
She agreed that Ms Lord should never have been put in that situation.
She would not agree that it was a ``system breakdown'' as previously suggested by witness Ross Ulman.
Ms Reed said the systems worked most of the time for the company's 35 aged-care homes and 2850 residents.
She said it was the company's practice to only place nurses in charge of a facility if they had been registered for at least three years.
She failed to inform Ms Renshaw of this practice.
After Mr Whiley's death, Tamar Park introduced formal medication training to carers and it now requires new nurses to be ``buddied'' by other senior nurses for five days.
Coroner Rod Chandler adjourned the inquest for written submissions from counsel.