Ken Godward, 76, and Roger Lamb, 79, passed away after being beaten by Harry Bosomworth, 70, who had schizophrenia, at St James's University Hospital in Leeds in February 2015.
Schizophrenic patient attacked elderly men on ward at St James'sAn inquest heard how Mr Bosomworth's behaviour had started to deteriorate prior to the incident, and that he was "suffering a psychotic episode" and believed that his home was being raided by intruders at the time of the attack.
Recording narrative verdicts, coroner Kevin McLoughlin told Wakefield Coroner's Court on Monday that there was no fault on the part of the hospital, that the incident could not have been foreseen and that the attack was only a contributory factor in each man's death.
Nursing chief's apology to families of Roger Lamb and Ken GodwardHe said: "That two men suffered in this way is a monstrous outrage, perpetrated in a hospital where they would have expected to have been safe.
"It is offensive to any right-thinking member of society that this should happen to them.
"We must establish how it was that a person came to be at their bedside with a weapon and be able to inflict such injuries."
The inquest heard how Mr Lamb had been trying to help Mr Godward when he sustained his injures.
Mr McLoughlin said: "That a 79-year-old man, who himself was suffering from his own illnesses, would go to the aid of a fellow patient speaks volumes.
"He deserves a commendation, in my submission."
Earlier this year, a leaked investigation report detailed how Mr Bosomworth was admitted to the hospital suffering from oesophageal cancer.
It explained how a decision was taken to stop an anti-psychotic drug despite warnings from his family.
Mr McLoughlin explained that the decision had been prompted by fears that the drug had contributed to two seizures that Mr Bosomworth suffered within days of being admitted, adding that there were "justified clinical reasons" for not prescribing the medication.
The inquest heard how Mr Bosomworth had been given a sedative drug in the early hours of February 28 after acting strangely, but was found at around 7am with his walking stick, standing close to the injured Mr Godward and Mr Lamb, wearing only his underwear.
Witnesses told how Mr Lamb, a former civil servant, had blood on his face, while an injured Mr Godward was in tears.
They both passed away days later, the inquest heard.
The coroner told how Mr Bosomworth had not demonstrated aggression in the lead up to the attack, and said that nurses had treated him in the correct way and were "vigilant" in regularly checking on him.
Pathologist Kirsten Hope said that the blunt force trauma suffered by both men contributed to their deaths.
But Dr Hope said Mr Godward's immediate cause of death was a chest infection caused by Alzheimer's, with Mr McLoughlin explaining how the injuries sustained in the attack had a "more than minimal contribution".
She said Mr Lamb also died from a chest infection, in his case caused by a fractured hip.
Passing on his condolences to the families, the coroner said that such incidents are "vanishingly rare" and were not a "cavalier oversight" on the hospital's part.
Speaking after the inquest, Lisa Dixon, Mr Godward's daughter-in-law, said that hospitals have now become "non-safe" places.
Addressing the coroner's view that the attack could not have been foreseen, she added: "If it wasn't preventable, why have the hospital spent two-and-a-half years doing changes to stop this from happening again?
"If this is a place where you go for safety, run by a government, then there's something radically wrong."
Yvette Oade, the chief medical officer at Leeds Teaching Hospitals NHS Trust, said that the conclusion that the incident was not predictable or preventable concurred with their own investigations.
Referring to Mr Bosomworth, she said: "What our investigation found was that both staff from the acute hospital and from the mental health hospital were working very well together to ensure he got the best possible treatment and care."
She added that work has been done to ensure that patient's families are aware that they are being listened to by medical practitioners.