Mr Fenwick’s wife and other family members were sitting in the gallery.

Presiding over the inquest, deputy state coroner Carmel Forbes heard during evidence given by interim director of mental health drug and alcohol Adrian Fahy that since the attack on Mr Fenwick changes have been made to include all staff treating a patient to notify escalating behaviour to a review panel and since the changes were implemented there has been a slight increase in patient review.

However he said it was only possible to review patients during working hours Monday to Friday due to staffing availability.

Mr Fenwick died of stab injuries when he came to the aid of a female nurse at Bloomfield in a low risk residential unit on January 6, 2011.

The name of the man who was a voluntary patient at Bloomfield at the time and inflicted the fatal wounds has been suppressed by the deputy state coroner.

During his evidence Mr Fahy was asked about the access patients had to kitchen areas where knives were kept and acknowledged photographs of knives taken at Bloomfield by detectives following the stabbing.

“In that setting they are benign but they are weapons in criminal law,” Ms Forbes said to Mr Fahy.

Mr Fahy when questioned told the inquest he was also unaware at the time of the attack on Mr Fenwick the door lock between residents’ sleeping quarters and the nurses’ station was faulty and could be manipulated.

“It did not have a robust locking system, he said.

STORY: NURSE KILLER FOUND NOT GUILTY

Later in the day consultant forensic psychiatrist Dr Samson Roberts who works in Sydney in practice and with inmates of Long Bay Jail, told the inquest he would have ordered a different course of treatment for the man who stabbed Mr Fenwick based on reports and interviews he conducted with him after he killed the nurse

Dr Roberts said he believed his behaviour would have been better managed by prescribing the drug clozapine, which is used in the treatment of schizophrenia, and in the lead-up to the incident would have recommended closer monitoring as the man was delusional and required adjustment to medication.

During questioning solicitor Graham Butler acting for psychiatrists who treated the patient at Bloomfield referred to medical notes by Mr Fenwick dated October 2010 and put it to Dr Roberts that Mr Fenwick had indicated the man was medium risk in the nurse’s assessment.

However Dr Roberts said the man’s psychiatric condition was such that could change at any time due to his mood swings.

“There was a highly changeable level of risk,” he said.

The inquest continues today.