An elderly resident of a Hunter dementia care unit became aggressive on multiple occasions in the weeks before he pushed his roommate to the ground, causing injuries that led to the man's death, an inquest has found.
Neville John Clutton died at John Hunter Hospital on February 10, 2017, almost two weeks after he was injured at Wallsend's SummitCare facility.
Deputy State Coroner Magistrate Robert Stone released his findings on Tuesday from the inquest into the 78-year-old's death.
Magistrate Stone found that Mr Clutton died from complications of head injuries after being pushed by another person, resulting in a fall.
He said Mr Clutton suffered facial fractures as well as bleeding on the brain and he was "not able to overcome the trauma".
The inquest found that Mr Clutton's roommate - an 80-year-old man who cannot be named - did not have a history of physically aggressive behaviour when he moved into the facility in mid-2016.
But the inquest found that the 80-year-old began acting in a physically aggressive manner at the end of 2016 - on one occasion grabbing a staff carer around the neck.
Magistrate Stone found that there were three incidents between Mr Clutton and the 80-year-old in the 10 days leading up to the fatal fall.
On the night of January 18, a registered nurse found Mr Clutton on the floor near his room - the 80-year-old had been seen dragging him out of their quarters.
Four days later, Mr Clutton was found on the floor of another person's room. The same day, the 80-year-old became verbally aggressive towards Mr Clutton and one of his close family members as they tried to enter the room - the 80-year-old slammed the door in their faces.
Two days after those incidents, a nurse heard Mr Clutton screaming.
She found him lying in the doorway of his room with the 80-year-old standing over the top, one leg either side of his body, yelling.
"He was in my stuff so I dragged him out," the 80-year-old told the nurse.
"I should kick him in the head until he's dead."
No-one witnessed the final incident on January 28, but one of the nurses suspected the 80-year-old's involvement because he was seen near Mr Clutton - who was bleeding on the ground - saying: "I am sick of your sh*t".
CCTV footage later showed the roommate had "pushed Mr Clutton with force".
The 78-year-old died in hospital 13 days later.
In his findings, Magistrate Stone did not take issue with the level of supervision at the dementia care unit.
But he criticised "poor record keeping", with insufficient or non-existent records of some incidents, and said the 80-year-old's behaviour was "given insufficient attention, particularly after the [initial] manhandling of Mr Clutton".
"From all the evidence it is acknowledged that keeping people safe, particularly those with dementia, in a residential aged care facility is not a simple task," he said.
"Those with dementia can exhibit a range of unusual behaviours in what would otherwise have been a placid human being.
"It is essential that these behaviours are better understood by those who are entrusted with the care of those afflicted with this condition."
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