Eating too much contributed to a Taradale man's death, a coroner has found.
The coroner has questioned the adequacy of supervision by special care agency IDEA Services after a the death of Paul Douglas Thompson.
He was 37 when he died in Hawke's Bay Hospital on the afternoon of April 8, 2013, three-and-a-half hours after arriving at the Emergency Department with abdominal pain, distension and vomiting.
Mr Thompson was a sufferer of the genetic, hunger-inducing condition Prader Willi Syndrome and Coroner Carla na Nagara has found he died of "severe metabolic and respiratory acidosis, secondary to gastric dilatation and physiological stress following ingestion of a very large volume of food."
He was undergoing diagnosis in hospital when he suffered a cardiorespiratory arrest and could not be revived.
Ms na Nagara, in a finding delivered this week and following an inquest on April 30, said that the care of Mr Thompson during the previous night, at the home where he lived, was inadequate in that recording of the amount of food he may have eaten was inaccurate "and thus probably under-reported," and that the response to his constant toileting and soiling, particularly from about 4am in the morning "was not proactive enough."
But the coroner said: "I do not consider these inadequacies led to Paul's death, but they are important matters in the wider factual matrix of his death."
The death was "the result of a myriad of variables, the most significant of which pertained to his specific medical condition, and to his clinical presentation that made his an extremely difficult case to diagnose."
She said it is "entirely reasonable" to expect those caring for vulnerable people to have appropriate training. But there was no evidence anyone was less than committed to doing their duty, and there could be no individual criticism.
"I consider this to be a training issue," the Coroner said. "Implicit in my findings is the expectation that these matters will be reviewed and addressed by IDEA Services, presumably by providing staff with more training."
She found Mr Thompson was appropriately treated by the general practitioner he saw on the morning of the day he died.
"He recognised that Paul was unwell, that the history was unclear and that the situation was serious, and expedited appropriate investigations in order to gain clarity as to the diagnosis and requisite treatment."
Mr Thompson had lived with three others in a community residential disability support services home which had a roster which allowed for double staff in the morning afternoon and evening and staff members staying overnight, and steps were in place to monitor and control his eating and access to food.