A senior nurse who feared an elderly man had killed a fellow aged care resident left the pair in the same room after she found the victim bashed to death in his bed, an inquest has heard.
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The man also wasn't under close surveillance by staff, despite a history of domestic violence, aggression and wandering, and a string of violent incidents in the days leading up to the death of Charles McCulloch.
Mr McCulloch, 94, moved into the dementia ward at Narrabundah Jindalee Aged Care on January 20, 2012.
The next morning staff pulled back the blankets of his bed to find him still and his face bloodied and battered.
An inquest into the circumstances of Mr McCulloch's death in the ACT Coroner's Court is looking at Jindalee's handling of Mr McCulloch's death, systemic problems and and supervision of high-needs dementia patients.
No individual worker is likely to be blamed.
The inquest previously heard nursing staff were told not to call police after Mr McCulloch was discovered.
His suspected killer was identified but never charged, due to his severe dementia, and has since died.
Lawyers for Mr McCulloch's family said they were concerned he may have been injured in an earlier attack involving the suspect and was not dead when staff found him.
But they said relatives had said they did not want to blame staff for his death, but simply wanted to find out what happened.
Jindalee registered nurse Miho Endo, who was the most senior staff member at the facility that morning, admitted on Friday it was possible Mr McCulloch could have been hurt in the argument between two other men in the room and not found until later.
The nurse recalled she screamed when she pulled black the blanket and saw Mr McCulloch's face was covered in blood.
She did not think to check vital signs, which was usual protocol, because Mr McCulloch was "obviously dead to me" and she was shocked and scared.
"Checking his pulse was the last thing I was thinking of at the time."
The woman said immediately suspected the elderly man had killed Mr McCulloch because he had been involved in four violent incidents in the previous few days.
She saw the man, who lived in the same room, sitting on a chair nearby.
But she left the room to alert management and later returned to find the Mr McCulloch with a pillow over his face and tissues stuffed down his throat.
Under questioning from counsel assisting the inquest Amanda Tonkin, Ms Endo said she had struck out some handwritten words in her notes from that day to say Mr McCulloch was covered with a pillow and blanket the first time she checked on him.
She said the error in her notes came about because she was shocked and confused.
The nurse acknowledged she should have called police straight away but didn't after a more senior staff member twice told her not to.
Instead, the staff member asked the nurse whether anyone had seen the incident and told her to call a doctor.
The doctor repeatedly advised the nurse to call police immediately, but she said she didn't right away because she didn't want to jeopardise her job.
The court heard the elderly suspect had been in a fight with another male resident about half an hour before Mr McCulloch was found dead.
He had a history of aggression and domestic violence and had also been prescribed Respiradol, an anti-psychotic drug.
The man been also been placed under surveillance after he previously tried to run away but that heightened level of supervision had not continued.
The inquest continues.
Correction: This article has been updated to clarify Ms Endo's evidence about notes taken after Mr McCulloch's death. Coroner Peter Dingwall does not plan to make any adverse findings against Ms Endo and described her as a credible witness.
