Seventy-two years later, at 89, he died in pain.

Mr Murphy, who suffered dementia, had swallowed cleaning fluid that was left in an unmarked bottle in his bathroom at his Gold Coast nursing home.

It took two-and-a-half hours for the Lions Haven for the Aged in Hope Island to call an ambulance after the incident on November 21, 2014.

Mr Murphy would die in hospital three days later.

It took another four years for a coronial inquest to start.

On Friday – more than two years after the inquest started – Coroner James McDougall handed down his findings in the Southport Coroner’s Court.

He gave just one recommendation and no one will face charges over Mr Murphy’s death.

But, for the family, the fight to get justice has only just started.

“No one has been found accountable and that is not OK,” granddaughter Kirsty Richardson said.

WHAT HAPPENED

Mr Murphy had been living at the Lions Haven for the Aged nursing home for about five years before his death.

He was in the early stages of dementia and had lost his wife to the same illness two years earlier.

About 11.30am on November 21, 2014 cleaner Janet Mason went into Mr Murphy’s room with a bottle of cleaning fluid, Bacban.

She left both the room and the surface sanitiser.

About 2.30pm that day, Mr Murphy was found coughing, producing excess saliva and complaining of a burning sensation.

The bottle of Bacban was found open next to him.

Clinical nursing manager and registered nurse Pamela Fox called the Poison Information Centre hotline but gave them the wrong information – that Mr Murphy was not presenting any symptoms and that he had only drunk a small amount of the fluid.

She was advised to monitor Mr Murphy and call paramedics if he started to show symptoms.

Lions Haven manager Catherine Newman was told about the incident immediately.

At 2.45pm she went home.

Two-and-a-half hours later the nursing home would finally call for an ambulance when Mr Murphy began to cough up blood.

Paramedics estimated Mr Murphy may have drunk up to 200ml of the substance.

Mr Murphy’s family was not told about the incident until the emergency department called his daughter Rhonda Willems to get permission to perform a medical procedure.

He was placed in intensive care where he died three days later.

THE WAR HERO

When Mr Murphy was 15 he was desperate to do his duty for this country when Darwin was under threat during World War II.

He did what many teenagers did – he lied about his age.

He was soon commissioned to a position as an anti-aircraft gun ammunition runner based in Berrimah, Darwin.

Just months before his death, he spoke to media at the 72nd anniversary of the bombing of Darwin on February 19, 1942 at 9.58am.

“If you got in the road, you got bombed,’’ he said. “That’s about it.’’

His time in WWII did not dampen his zest for life.

“He was fun-loving and loved his music,” Ms Willems said.

“He danced. He and mum were still dancing when she died.”

Mr Murphy was also described as a family man who moved to the Gold Coast in 2009.

LIONS HAVEN

Coroner McDougall found that it took Lion’s Haven Aged Care two-and-a-half hours to call the ambulance.

He said the nursing home’s response was “inadequate”.

“Early attention would have been unable to prevent death but it is likely it he would have been made more comfortable,” he said.

A number of shocking facts were unveiled during the coronial inquest, including:

* The wrong information was given to the Poisons Information Centre.

* Observations about Mr Murphy’s condition were not recorded on his medical chart.

* The manager left the facility for home 15 minutes after being told about Mr Murphy’s predicament.

* Two registered nurses were responsible for 60 people.

Mr McDougall said since the incident Lions Haven had made a number of changes including making dispensation of chemicals automatic, chemicals to be placed on a lockable cleaning trolley, cleaning trolleys were to be taken into rooms so none were left unattended and after cleaning each room a chemical sign-off sheet was to be completed.

Lions Haven declined to comment following the inquest.

CORONER’S RECOMMENDATION

Mr McDougall made just one recommendation following the inquest – that the Poison Information Centre treat all poison cases as worst-case scenario if the amount of poison ingested is unknown.

Through his findings, Mr McDougall concluded the cleaner Ms Mason had forgotten to take the Bacban with her after cleaning the room.

“There is no suggestion this was done deliberately but this error contributed to his death.”

He also found that paramedics should have been called as soon as it was discovered the poison had been ingested – not two-and-a-half hours later.

WHAT HAPPENS NOW

“There is no closure, it’s disappointing,” Mr Murphy’s daughter said.

Ms Willems and four other family members tearfully spoke to the Bulletin, saying the lengthy proceedings kept bringing up the painful memories.

Still, they do not feel like they have justice for their loved father, grandfather and great-grandfather.

“There still needs to be some consequences for their actions,” granddaughter Ms Richardson said. “This is not over.”

Ms Richardson said the family would be making complaints to the health ombudsman and Australian Health Practitioner Regulation Agency, and pursuing options in the civil court.

The family said while Mr Murphy was 89, he was still quite active and healthy.

“He may have been old but he still would have lived another couple of years,” Ms Richardson said.

The family have sworn they will keep fighting for justice.

lea.emery@news.com.au