Charles McCulloch's family were expecting a celebration on the 94-year-old's second day at a nursing home in Canberra.
It was his granddaughter's birthday, and there were to be a string of visitors to help welcome him to life at Jindalee Aged Care Residence in Narrabundah.
Instead, they were left identifying his body, and imagining the final moments before he was beaten to death by a fellow resident in Jindalee's secure dementia ward.
It has raised serious issues about the response to the death, and about resource and funding-starved nursing homes.
Distressed staff, many of whom were facing an unprecedented situation, failed to immediately call police.
Mr McCulloch's body was left unsupervised for long periods, while the man responsible was left to roam free.
His suspected killer had assaulted another man in the same room earlier that morning, but staff failed to check if anyone else had been attacked.
Concerns have been raised about the low staff-to-resident ratio, and about the placement of the suspected killer in the room with Mr McCulloch, given his violent past.
It took about an hour between the discovery of Mr McCulloch and a call to the police. Staff who found him did not take his vital signs, and the family fear he may not have been dead.
Nursing directors denied allegations they weretrying to cover up the death by not immediately calling police, and have defended claims they gave an inaccurate, more favourable version to the then Department of Health and Ageing.
On Thursday, local dementia expert Dr Tony Jones spoke of the difficulties of predicting violent behaviour, and of the precarious balance between staff's duty to keep residents safe with residents' right to freedom.
He praised Jindalee, saying the staff were the "most informed, sensitive, and professional" in the ACT.
Yet, throughout the inquest, little detail has emerged about the kind of man Mr McCulloch was, and just how much his shocking death has hurt his family.
That changed on Thursday afternoon, when his granddaughter read a statement on behalf of the family to the court.
"Until five months before Charles was killed, he lived at home in Forster, NSW, on his own, having outlived his very beloved wife," she said.
"Charles was a very charming man who people were always happy to help. We visited him as often as we could from Canberra and Melbourne and he would put us up in his spotless home and cook for us each day."
The family spoke of the agonising decision to place him in a nursing home after a fall and a diagnosis of dementia, and of bringing him to Canberra, where the majority of his family lived.
He moved to Jindalee on January 20, 2012, arriving via air ambulance. A big celebration was planned for the next day.
"Instead of visiting him the next morning, dad had to identify Charles' body," his granddaughter said.
"The rest of us just have our imagination about his injuries, informed by the knowledge that the nurse on duty ran screaming from the room at the sight of his face."
They spoke of losing faith in residential aged care, and their fear of having to ever move into a nursing home.
"We suspect that at least some factors that contributed to Charles' horrible death are systemic and ongoing, relating to staffing, training, regulations, funding arrangements, and ageism."
"There is no quick cure for problems in those areas, although we are grateful for any suggestions His Honour [Magistrate Peter Dingwall] may make to speed improvement."
"To my mind, our natural fear of the nursing home environment will be the lasting impact of Charles' death, and will only grow as we all age."
Jindalee's managing director Gary Johnson gave the family his condolences on Thursday, admitting Jindalee had failed to keep Mr McCulloch safe.
He also spoke of the changes that had been implemented at the facility since, to ensure that such an incident would not be repeated, and of the funding difficulties following recent federal cuts.
The coroner, Mr Dingwall, also passed on his condolences.
"We can only hope that what comes out of this will ensure something like this never occurs again," he said.
He has reserved his findings.
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