An ACT coroner says he expects an inquest into the death of a man killed at a Canberra aged care home will lead to recommendations aimed at preventing anything like it happening again.
Charles McCulloch, 94, was found beaten in his bed a day after he was moved into the high-needs dementia ward at the Jindalee Aged Care Residence in Narrabundah in January 2012.
It is believed he was killed by his roommate, who had already been involved in other violent incidents at the home.
The man believed responsible for his death has since died.
An inquest into Mr McCulloch's death has wrapped up, with coroner Peter Dingwell foreshadowing significant recommendations about nursing home operations.
Family of McCulloch also paid tribute to him, reading a statement to the court recalling Mr McCulloch as a charming man who had lived independently until a year before his death.
"Charles was far from completely lost to dementia. He had good days and bad days," they told the court.
He had been moved to Canberra to be closer to his immediate family.
They described their own grief at imagining how he had died, but stopped short of blaming any one person.
Instead they urged the court to make recommendations to prevent anything like it happening again.
"From the inquest proceedings so far it seems that it will be inappropriate to lay blame at the feet of any individual staff member for allowing the conditions that enabled Charles' murder to occur," they said.
"We suspect that at least some factors that contributed to Charles' horrible death are systematic and ongoing.
"There is no quick cure for problems in those areas, although we are grateful for any suggestions his Honour may make to speed improvements."
The home's owner agreed there was a failure and staff had not been trained for such an incident.
A final ruling is not expected until mid-year.
Read more at http://www.abc.net.au/news/2016-04-21/major-recommendations-for-nursing-homes-flagged/7347906