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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

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