Robin Walter Beets, 84, died in November 2023.
By Sam Sherwood of RNZ
The death of an elderly man at a dementia unit following an altercation with another patient was a “tragic outcome that was preceded by a sudden eruption of anger without a known cause or warning”, a coroner says.
Police decided not to charge the patient with manslaughter. The family of the man did not want the patient charged and said the “best outcome is to ensure this doesn’t happen again to other families”.
Coroner Ruth Thomas’ report into the death of Robin Walter Beets in November 2023 was released to RNZ.
The report said the 84-year-old was living in the Stokeswood Care Home dementia unit in Lower Hutt.
Nurses and caregivers said Beets was a “gentleman” and a “lovely guy”.
In August 2023, Beets was assessed as needing Dementia Level 3 secure residential care and placed in the dementia unit operated by Bupa Care Service.
The unit co-ordinator said Beets required full assistance with daily living, orientation and direction.
“She said he liked to keep himself busy, he had previously worked as an engineer and would try to fix things like the stereo at the dementia unit even when it was working fine. He would sometimes move furniture around, which would frustrate other residents who became triggered by the noise of the moving,” the coroner said.
Coroner Thomas’ report discusses another patient who was staying at the facility. Staff recorded the patient could become “triggered by loud noises at times”.
“The staff had a care plan in place to manage [the patient’s] behaviour with de-escalation techniques and medication as needed. The staff found this was effective as he was easy to calm down and re-direct.”
A medical note for the patient said his “unsettled and aggressive behaviour” on some afternoons was because of sundowning.
“Sundowning is a deterioration in cognitive function and occurs in the late afternoon or evening. [The patient’s] medication regime was adjusted, and this was helpful in reducing his agitation. Staff were aware of this behaviour and would redirect and distract [the patient].”
On the evening of November 9, 2023, Beets was seated at a table with two other residents near a bookshelf. The other patient was sitting at a different table with other residents.
A nurse said she was walking along a corridor when she heard the emergency alarm went off, so she ran back to the dementia lounge.
She saw Beets lying on his back near the bookshelf and the other patient was “on his knees with Mr Beets”.
The patient was shouting at Beets and was pointing at him with his hand “like the gesture you use to tell a person off”.
A caregiver said she was looking at some medication alongside a colleague and could hear some residents talking as well as the sound of chairs moving behind her and the patient shouting.
“In her peripheral vision she saw [the patient] near Mr Beets’ table. They were both standing, facing each other and [the patient] was holding Mr Beets’ collar. Mr Beets stepped backwards away from [the patient] and fell on to the floor.”
She described seeing the patient kneeling next to Beets with his arm raised and his fist clenched.
“Mr Beets was screaming in pain and [the patient] was yelling.”
The caregiver ran over and told the patient to stop and helped him to stand up. Another staffer got the patient away from the area.
The caregiver then noticed the dining chair Beets had been sitting on was on the floor, and thought he may have tripped over it.
The other caregiver who was also looking at the medication reported seeing both men standing face to face by the bookshelf.
The patient was holding Beets’ shirt collar. She described the patient as holding his right arm up with a closed fist.
“She then saw Mr Beets take two to three steps backwards, trip over a dining chair that was behind him, and fall to the ground.” She also saw the patient fall to the ground.
Beets was eventually transferred to Hutt Hospital where he underwent hip surgery the following day. There were no complications from the surgery; however, his health declined in the days afterwards and he developed aspiration pneumonia. Beets died on November 20.
A falls investigation report, carried out by Bupa, recommended new registered nurses receive further education to increase their knowledge of the fall prevention management in the dementia unit. The shared learning lessons part of the review said the unit had a staff meeting about early detection and intervention of residents in an altercation and ensuring clear documentation of an event and management.
Police sought an expert opinion from a consultant psychiatrist as part of its investigation. The psychiatrist said the patient would be “entirely unable to understand the charge, nature, purpose or consequences of court proceedings, unable to instruct defence counsel, unable to enter a plea and unable to participate in a hearing”.
It was his opinion that the patient would be unfit to stand trial. Police decided not to charge the man with manslaughter. As part of the investigation, police spoke with Beets’ family who said they did not want anyone charged adding “the best outcome is to ensure this doesn’t happen again to other families, in Stokeswood, or any care facility”.
Coroner Thomas said Beets’ family had questioned the circumstances surrounding his fall to understand whether anything could have been done to prevent it.
A Coroners Court clinical adviser reviewed the evidence and said the incident was “very unfortunate but unpredictable and not preventable”.
“Although incidents like this can be assumed at some level to probably have some sort of trigger in the person’s mind, it is often impossible, even in retrospect, to identify what it was. I am of the view, based on the provided information, that the staff provided very good care for [the patient], and did everything in their power to prevent the assault.”
Coroner Thomas said her assessment of the evidence in the inquiry revealed a “tragic outcome that was preceded by a sudden eruption of anger without a known cause or warning”.
“The staff had been actively managing [the patient’s] behaviour in the unit, but tragically on this occasion with no warning of a change in [the patient’s] behaviour, and both staff momentarily facing away from where the incident started, there was not enough time for staff to pre-emptively intervene and redirect [the patient] before he had grabbed Mr Beets by his collar. This incident took the staff by surprise, was unpredictable and I do not find the staff could have done more to prevent this altercation and therefore the tragic consequences that followed.”
In a statement to RNZ, Beets’ family said he was a “much-loved” husband, father, Grandad and Poppa who was “very practical, mechanically capable and a friend to many in Petone”.
“He was a very caring man, had a great laugh and was always willing to help others.”
Beets was diagnosed with dementia formally in early 2021, and as he deteriorated, the family decided that he go into fulltime care in August 2024.
“Dementia is a terrible disease for both the individual and their family. As is expressed in the report, we have never wanted the other party who also suffered from this disease to be charged or punished for this incident.
“What was important for us as a family was to see if there were lessons to be learnt which may prevent another family suffering a loss in the same way. We appreciate the thorough work done by both the Police and the Coroner, especially that the specific questions we asked were addressed within her report. We also note the internal review that the Care Facility undertook which resulted in additional training and support being put in place.”
A Bupa spokesperson said it acknowledged the coroner’s findings and the conclusion that this incident was “unpredictable and surprising”.
“Our thoughts remain with Mr Beets’ family, and we recognise the distress this event caused them. Moments like this are profoundly sad for everyone involved, and we continue to extend our sincere sympathy to the family.”
Aged Care Association chief executive Tracey Martin said in a statement to RNZ the case highlighted a “broader and growing reality”.
“Aged residential care is supporting residents with increasingly complex behavioural and clinical needs, particularly within dementia care settings.
“Dementia units are caring for people with significant behavioural and psychological symptoms, often in environments that were not originally designed for the intensity of today’s care requirements. As the acuity of residents rises, so too does the need for workforce support, training, clinical backup, and appropriate funding settings.”
She said while the coroner had not made recommendations, the case reinforced the importance of “continued investment in dementia capability, staff training, and system settings that recognise the complexity of modern aged care”.
Detective Inspector John van den Heuvel said as New Zealand’s median age continued to rise, the number of people living with dementia was also expected to grow.
“While fatal incidents within dementia units remain rare, resident‑on‑resident assaults do occur from time to time that require police investigation. This can be a difficult and sad situation to deal with for everyone involved.”
People living with dementia often experienced significant cognitive impairment, meaning they may not fully comprehend their actions or form the intent required to be held criminally responsible, he said.
“As a result, the evidential test for prosecution is frequently not met, and pursuing criminal charges is unlikely to be in the public interest. Police assess these matters carefully and in close consultation with medical specialists, care providers, and legal advisers. In cases involving a death the coroner is also consulted.”