A coroner has found a "gross dereliction of proper management" at an Adelaide nursing home where an elderly resident was bludgeoned by a dementia patient.
Dorothy Mavis Baum was hit with a chain and was found in her bed with serious wounds to her arms and face. The 93-year-old died in hospital the next day.
In his findings on Thursday, coroner Mark Johns said during her attack in May 2012, 85-year-old Rozalia Setalo also punched and threw items at staff and used her walking frame to hit them before eventually being subdued.
But he said it was unacceptable that two staff members at St Basil's Aegean Village barricaded themselves in the nurses' station for a period of time during the incident.
Mr Johns said carer Harit Kamal and registered nurse Ute Latz were duty bound to expose themselves to a risk of being attacked because a failure to do so might expose far more vulnerable people to injury.
"That risk was not merely theoretical because Ms Setalo clearly attacked and grievously injured Mrs Baum while the latter was helpless in her bed and unable to escape," the coroner said.
"Mrs Baum no doubt would have been terrified during this attack.
"The situation is made even worse by the fact that for at least two hours and probably longer, Mrs Baum was left bleeding.
"She was lying in her bed in her own blood."
The coroner said both nurse Latz and Mr Kamal believed Mrs Baum's injuries were self-inflicted which compromised a proper investigation into her death.
He said he also found it "entirely inadequate" that those managing the nursing home escaped any sanction.
He hoped that operational changes introduced to the Commonwealth Aged Care Framework in 2018 would ensure a greater level of accountability in the senior management and governing boards of nursing homes such as St Basil's.
The coroner called for them to be subjected to a system of personal accountability when standards of care were not met.
"Only by adopting a scheme in which there is some personal risk to those involved in the management of aged care providers at the highest level could the public be confident that an event such as the appalling treatment of Mrs Baum in life and then in death could not happen again," Mr Johns said.