A nursing assistant who found an elderly man bashed to death in his bed has told an inquest he was too shocked by the sight of the resident's bloodied face to check his pulse.
Charles McCulloch, 94, was found dead one day after he moved into the secure dementia ward of Narrabundah's Jindalee Aged Care Residence on January 20, 2012.
An inquest into the circumstances of his death began earlier this year and continued in the ACT Coroner's Court on Thursday.
It will scrutinise whether there are systemic issues with Jindalee's handling and supervision of high-needs dementia patients.
An earlier hearing was told nursing staff were told not to call police after the man was discovered bashed to death in his bed.
Shocked staff also left the man's body unsupervised for long stretches, allowing it to be interfered with, while the suspected killer was left free to roam the ward and assault other residents.
When staff came back, a pillow was over his face and tissues were stuffed down his throat.
The inquest heard that the man suspected of the killing, who is now dead, had been in a fight and punched another man earlier that morning.
He was taken for breakfast, and then allowed to go back to his room.
On Thursday, lawyers for Mr McCulloch's family told the inquest they had concerns about the lack of supervision and that Mr McCulloch may not have been dead when staff first found him.
The inquest was shown a re-enactment of the events that led up to a Jindalee staff member discovering Mr McCulloch's body in his room.
The nursing assistant, who had trained as a nurse overseas but was not registered in Australia, said he had gone into Mr McCulloch's room to give him some porridge about 7.30am.
He saw the shape of a body and two feet underneath the blankets, which were drawn over the man's face.
When he pulled back the blankets he saw blood flowing from Mr McCulloch's nose and mouth. He wasn't moving and appeared to already be dead.
The nursing assistant told counsel assisting the inquest Amanda Tonkin that he rushed outside to tell staff, saying "something terrible happened".
He didn't test the man's pulse and said that Mr McCulloch "looked like he was dead but I didn't check".
The inquest was told he also didn't check whether anyone else had been in the room because he didn't have the presence of mind at the time.
"There's no reason [why I didn't check], but I was really shocked with the scene."
The man told the court he didn't notice blood on the walls or bedhead at the time.
He also didn't see anyone in the room when he returned soon after to pull the blanket back over Mr McCulloch's face and draw the curtain around his bed closed.
The worker said he didn't make note of the incident because he was shocked, and he didn't write up an incident report.
Mr McCulloch's suspected killer was identified but never charged, due to his severe dementia, and has since died.
The inquest is examining systemic matters, such as supervision, the lack of CCTV monitoring, and whether increased staff-to-resident ratios could help safety.
No individual worker is likely to be blamed.
The inquest is the third concerning the Jindalee facility in Narrabundah in recent years.
One of those inquests recommended CCTV be installed in parts of the dementia ward, but that measure was not adopted
The hearing will continue before Coroner Peter Dingwall on Friday.