A dementia patient wandered into the room of a dying man yelling “get him out of my f*****g bed”, while the man’s family desperately tried to call nearby staff.

The next day, the same patient returned and yelled at the unconscious man to wake up before punching a healthcare assistant and then grabbing at the man who was later found lying on the floor with blood on his head. He died several hours later.

The dead man’s family say he died without dignity and made an official complaint into his care at the Tauranga rest home.

Today the Aged Care Commissioner Carolyn Cooper concluded Radius Care, the operators of the home, provided “suboptimal care” by failing to adequately inform the man’s family of the issues, and failing to provide adequate staffing levels.

The now-deceased patient, identified in the report only as Mr A, was placed into the care of Tauranga’s Radius Althorp in 2019.

Aged in his 70s, he suffered from dementia, Alzheimer’s, pancreatic cancer and broader cognitive impairment.

Shortly after moving in, Mr A found a neighbouring resident in his room. He punched the resident identified as Mr M, before being bitten by Mr M on the arm.

The man was a previous resident of the room Mr A occupied. He too had dementia as well as a history of territorial behaviour. He was later removed from the home to undergo mental health treatment.

Just over a fortnight later, another resident entered Mr A’s room, where he responded by hitting them with a stick. The resident was removed, but the incident was not documented in Mr A’s notes.

Six days later, Mr M had returned from treatment and again entered Mr A’s room. Mr A attempted to punch him before he was removed.

Around three weeks later, Mr A’s daughter raised concerns about intruders entering her father’s room. Over the following weeks, Mr A’s health deteriorated rapidly.

The man died just hours after another resident attempted to attack him. Stock photo / 123rf

Another incident saw Mr M enter Mr A’s room raising his fist. Mr A then went about blocking his door with four chairs, preventing anyone from entering.

That same afternoon, a doctor deemed Mr A was likely approaching the last days of his life. Care notes show his family was “informed” but did not reference an end-of-life plan.

The following morning, Mr A was found in his room crying, saying he had “two days left”.

The next day, Mr M again entered the dying man’s room while his family was visiting. Mr M yelled “get him out of my f*****g bed”, while the family desperately tried to call nearby staff.

“The [emergency call button] didn’t appear to work, and nobody came for what seemed an age,” one family member told the commissioner.

The family asked for Mr A to be moved, but staff said there were no spare rooms.

The next day, Mr M once again entered Mr A’s room. He was unconscious and Mr M yelled at him to wake up.

“[Mr M] turned to me and punched me on the arm twice yelling at me ‘hey’. He turned back to [Mr A] grabbing his top and shook him telling him to get up from the bed,” a healthcare assistant at the home recounted to the commissioner.

She went out of the room to call further staff, arriving back to find Mr A on the floor. Mr M was eventually removed, and staff noticed blood on the back of Mr A’s head.

Throughout the ordeal, Mr A remained unconscious. He was found to have had a “small tear” to the back of the head. He passed away later that afternoon.

An autopsy recorded the cause of death as pneumonia, with cardiovascular disease and pancreatic cancer being contributors.

The autopsy report noted the brain showed signs of cerebral ischaemia (a lack of oxygen). It was “difficult to determine” if that specific condition came about due to the assault or other factors.

Radius launched an internal investigation into the repeated intrusions and the man’s death. It found over six shifts, key care assessments were not carried out to determine what level of care Mr A required.

A care plan also wasn’t adequately formed to deal with Mr M’s territorial behaviour. It also found staffing levels in the dementia unit were inadequate.

Mr A’s family told the commissioner he died without dignity. The family would have arrived at the home much earlier had they been informed of the final incident hours before Mr A’s death.

 “In my view, there were deficiencies in the care provided to Mr A by multiple staff at Radius Althorp. These were systemic issues for which Radius Althorp bears responsibility,” Cooper found.

“The overall deficiencies in the end-of-life care provided to this man, the inadequate documentation and staffing levels at Radius Althorp, and the inadequate communication with the man’s family, demonstrate a pattern of suboptimal care and a lack of critical thinking from Radius Althorp staff members.”

She recommended Radius provide a written apology, detail efforts taken since its internal investigation, and conduct a random audit of end-of-life care plans over the previous six months.

The report says since the events, Radius Althorp has provided staff with further training and increased staffing levels.