A 67-year-old male resident suffering "severe dementia" - who cannot be named - bent Hazel Brockett's leg up to near her head and broke her arm, an inquest into the 86-year-old's 2016 death found.

Deputy State Coroner Robert Stone said in his findings, released last week, that the assault came after increasingly frequent instances of verbal abuse and violence from the 67-year-old over several months.

When a staff member heard Mrs Brockett scream from her room just after 2pm on July 14, the carer arrived to find the man holding her arm in the air. Her left leg had also been bent up to near her right ear.

Magistrate Stone recounted the carer's evidence that she remembered the man was saying words similar to: "Don't scream darling, I am not trying to hurt you" and "I'm just trying to get the poison out".

Mrs Brockett was taken to John Hunter Hospital but her age complicated surgery to repair her fractures. She died in hospital on July 23.

Magistrate Stone said not enough had been done to deal with the man's behaviour before the assault on Mrs Brockett - paperwork following incidents did not always accurately reflect his behaviour and there was a communication breakdown between staff at the care facility and the man's GP.

But he said the staff were "people who were trying to do their best in what has been termed as a very challenging environment".

"On the evidence, [the man's] behaviours were increasing with frequency and measures needed to be taken to address it," Magistrate Stone said.

"With the available staff at the facility at the time I find there was a risk to the safety of others due to his escalating behaviours."

Magistrate Stone did not make any findings about staffing levels - two carers on duty for as many as 11 residents - but he said staff "must have been stretched".

His recommendations largely dealt with improvements to procedure and policy at the facility.

Tom Brockett, Hazel's widower, told the Newcastle Herald on Tuesday he wanted better training for carers who work with dementia patients.

Mr Brockett said he believed more action should have been taken to make the care facility safer for residents, given the 67-year-old man's behaviour in the first half of 2016.

The man was involved in three-to-four aggressive incidents per month between January and April, with 22 documented in May and 29 recorded in June.

Magistrate Stone said the man "was not in a position to fully appreciate either the nature or consequences of his actions".

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