Rest home nurses who rushed to an 82-year-old dementia patient's scream found her on the floor with another patient's walking frame on top of her.
The patient, Nola Revell, was taken to hospital and died four days later.
Hastings coroner Chris Devonport released a report on the death last month,
saying CCTV cameras should be installed in rest homes to monitor incidents. The only witnesses in the case had advanced dementia and could not testify.
Just before lunchtime on a Sunday in June last year, Mrs Revell and 13 other residents at Gisborne's Dunblane rest home were walking from the home's lounge to its dining room, the report says.
Mrs Revell did not use a walking frame and walked ahead, while two healthcare assistants helped residents on walking frames.
Then a nurse, halfway down the corridor, heard Mrs Revell scream and ran to the dining room.
She found three residents: Mrs Revell, on the floor with a walking frame on top of her; a male resident pulling on Mrs Revell's arm; and another male resident some distance away.
The man who had been pulling Mrs Revell's arm did not use a walking frame, but the other man did.
Mrs Revell was taken to hospital and had surgery that day. But her condition deteriorated and she died four days later.
Police inquiries could not find out what had happened because there were only two witnesses the two men in the room, both suffering from advanced dementia and unable to communicate effectively.
A staff member said "Mrs Revell was constantly 'in the faces' of residents and yelling at them to help her", the report says.
"Of note is the observation by Dunblane staff that Mrs Revell would 'nag' male residents to let them 'take her home' on the front of their walkers."
Mrs Revell and the man who had been kneeling over her had had a previous altercation, with Mrs Revell reported to have been constantly "annoying and grabbing at" him.
In April, he had retaliated, pulling on Mrs Revell's arm and tearing her skin.
Mr Devonport said it could not be known exactly what had happened, and recommended CCTV cameras to monitor residents' movements and suggested increasing staff during mealtimes.
