A 37-year-old man who died after eating 24 muesli bars, eight hamburger buns and three loaves of bread should have been cared for better at his disability support home, a coroner says.
Paul Thompson died in April 2013 from increased acidity in his blood and severe stomach bloating and physiological stress caused by "gorging himself on a large quantity of food", a Coroner Carla na Nagara has found.
Mr Thompson had a rare congenital disorder which causes obsessive eating, and carers had to monitor him from an early age to make sure he wasn't stealing food or cash to buy food.
The 37-year-old had been living at a home for people with disabilities in Napier on April 7 when the overnight caregiver, who'd been working there for two-and-a-half months, noticed he had an upset tummy.
Mr Thompson made frequent trips to the bathroom during the night, soiled the hallway floor, and asked for his caregiver's help when he needed to change his sheets for the third time.
When she helped make his bed, the caregiver found a hidden set of keys which he admitted he'd stolen from the office when the door was left open.
The next day, he went to his day programme, but was taken to a GP when his service worker noticed he was waddling, pale and having trouble breathing.
He was later taken to Hawke's Bay Hospital - and three-and-a-half hours later he was dead.
In her report released today, Coroner na Nagara said the food wrappers found in Mr Thompson's room suggested he had been overeating that night while the care worker was there.
She found there was nothing more the GP, who didn't know Mr Thompson's full medical history, could have done.
But she called the care provided by staff at the home "inadequate", saying the response to his constant toileting wasn't proactive enough, and the recording of the food he may have eaten was inadequate.
"I intend no personal criticism of individual workers as there is no evidence anyone was less than committed to discharging their responsibilities adequately, and I consider this to be a training issue," she said.
Coroner na Nagara said she expected the home to review and address this.