Coroner's Finding: Rosendale, Dwayne Edward
Deceased
Dwayne Edward Rosendale
Demographics
36y, male
Date of death
2019-01-17
Finding date
2021-11-04
Cause of death
Complications of morbid obesity, including cardiac enlargement, aspiration of gastric contents and sleep apnoea
AI-generated summary
A 36-year-old man with treatment-resistant schizophrenia and Capgras syndrome died from complications of morbid obesity (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respiratory failure and returned to Bayview Lodge, a supported accommodation facility without medical oversight. He died two days later from cardiac enlargement, aspiration of gastric contents, and sleep apnoea, likely precipitated by alcohol and clozapine (found at therapeutic levels despite not being prescribed). Key clinical lessons: he required residential care with 24/7 supervision and strict caloric monitoring, which Bayview Lodge could not provide; FMHS identified the housing mismatch but failed to relocate him; there was poor discharge communication (summary sent to a GP he hadn't seen in 4 years, not to FMHS); and medication supervision was unclear between hospital and community. The preventable element was delayed relocation to appropriate higher-level care despite documented concerns from staff.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Morbid obesity (183.5 kg, BMI 45.3)
- Chronic obstructive pulmonary disease and sleep apnoea
- Cardiac enlargement secondary to obesity
- Heavy smoking and tobacco dependence
- Treatment-resistant schizophrenia
- Antipsychotic medication causing weight gain (zuclopenthixol)
- Somatic delusions preventing physical exercise
- Consumption of junk food and sweet drinks while in supported accommodation
- Alcohol intoxication on evening of death
- Inappropriate residential setting (Bayview Lodge) unable to provide required caloric supervision
- Lack of engagement with general practitioner
- Unclear medication supervision between hospital and community
Coroner's recommendations
- Forensic Mental Health Services review their policy (or develop one if it does not exist) regarding expectations of residential accommodation providers, particularly concerning medication administration and supervision, and consider entering into Memoranda of Understanding where expectations of involvement exist.
- Tasmanian Health Service amend Patient Discharge Summary procedures at Royal Hobart Hospital to ensure discharge summaries are provided to patients' treating Forensic Mental Health Service practitioners.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —