It was in the early hours of the morning on January 22, 2008, when someone crept into a patient's room at a Melbourne medical centre carrying an unnecessary dose of insulin.
Two weeks later, another elderly patient at the same Caulfield facility was targeted with an injection of the same medication.
It was later discovered these two women had their jewellery stolen after being drugged. The only nurse on duty in that ward on both occasions was Megan Jean Haines, a South African-born woman who was this week convicted over a double murder.
"[It's] a pretty well-off area," a former colleague said in an interview with Fairfax Media.
"So, most of the patients just had these beautiful old diamond rings and things.
"And they were given insulin right at the end of the shift so they wouldn't be roused by the next person rostered on and find it missing."
Six years later, after fighting to get her nurse's registration reinstated after a succession of troubling misconduct findings, Haines used insulin as her "murder weapon" to kill Marie Darragh, 82, and Isabella Spencer, 77, as they slept inside a NSW nursing home in 2014.
The elderly residents were two of three people who had reported Haines for her rude remarks, rough-handedness and unwillingness to help.
The jury responsible for finding her guilty of the 2014 murders in the NSW Supreme Court this week were unaware of her chequered history: the damning misconduct findings, drug conviction, assault and theft investigations and insulin misuse suspicions.
Equally oblivious were the relatives of her murder victims.
"I am shocked and absolutely appalled she got her nursing registration back," Ms Darragh's daughter Charli Darragh said on Friday.
"I can't fathom it. I am lost for words."
Following Haines' conviction last week, the litany of problems that have shadowed her nursing career can finally be revealed. Haines came to Australia in 2000 and registered as a nurse in Victoria the following year.
Within five years she was the subject of her first complaint investigation after failing to care for a patient at Box Hill Hospital.
Two years after that complaint, another was made about Haines threatening to access patient information at Maroondah Hospital.
Also in 2007 she was reported for an alleged minor assault, understood to be slapping or pushing a patient, at Caulfield Medical Centre.
However, the most serious allegations, stemming from her time as a nurse at the same centre, were yet to come.
After routine blood tests picked up the presence of insulin in the systems of two elderly patients at the facility in early 2008, suspicion fell on everyone, a former colleague of Haines' said.
The drugged patients' missing jewellery was then uncovered but it was unclear who the culprit was.
One of the women had a security guard posted outside her room because of fears that whoever was responsible could return.
"This poor patient, they didn't know what had happened, so they put a guard outside her door until it was worked out," the former colleague said.
"Everyone was a suspect at that point."
Three days after the second patient was drugged, police searched Haines' Boronia home.
They didn't find any jewellery but there was a small amount of drugs, believed to be cannabis, prompting a charge for drug possession.
It is understood that police did not further investigate the suspected drugging of patients after failing to find the jewellery.
A person familiar with the investigation said this was because neither patient was left seriously ill, and, without finding the missing jewellery, there was nothing that proved someone had intended to harm them.
The Nursing Board of Victoria stripped Ms Haines of her registration in February 2008. A year later she applied to have it reinstated, but was knocked back because her third misconduct probe was still going.
After the watchdog system for health practitioners moved from a state to a federal model, Haines made another bid for her registration in 2012 through the former Australian Health Practitioner Regulation Agency.
This time she was successful.
AHPRA, which has refused to comment on its decision citing Haines pending sentence hearing, attached reporting conditions to her registration.
This initially hampered her effort to get a job until St Andrews Village in Ballina took her on in 2014.
Haines was working her sixth shift on May 9 that year when she learned she had fallen into the centre of yet another complaint investigation. After ripping open the envelope holding the written complaints about her, Haines injected insulin into Ms Darragh and Ms Spencer.
Another resident, Marjorie Patterson, had also made a complaint about Haines and woke up on the night of May 9 to the nurse giving her Panadol, a practice Ms Patterson told police had never happened before.
Several days later Haines resigned and in July of that year she was arrested and charged over the nursing home murders.
It is understood the NSW Homicide Squad arrests prompted Victoria Police to again investigate the jewellery theft and mysterious insulin injections years earlier at Caulfield Medical Centre.
Haines' relative told police that another relative had visited the nurse in Mullawa Women's Detention Centre in Silverwater on July 11, 2014.
Haines told that visitor to remove some unique jewellery from behind a power point at her home in Seaspray, in East Gippsland.
But police had been told the jewellery had already been removed and given it to a friend, with instructions to remove the stones from a ring and melt the rest down.
Police believed a relative either pawned rings stolen from patients himself, or used a friend to do so.
Officers searched two properties in country Victoria looking for evidence that could link Haines to the Caulfield thefts but came out empty handed.
Haines will face a sentence hearing in the NSW Supreme Court on December 7.
