Coroner's Finding: Mather, Robert Andrew
Deceased
Robert Andrew Mather
Demographics
80y, male
Date of death
2021-11-11
Finding date
2022-12-15
Cause of death
asphyxia due to choking on food
AI-generated summary
Robert Mather, 80, died from asphyxia due to choking on food while hospitalised with acute psychosis, severe malnutrition, iron deficiency anaemia and urinary retention. He had schizophrenia with 40+ year history and poor compliance off medications. Clinical deterioration was profound: 3-week religious fasting causing significant weight loss, unattended for 5+ years by GP, bladder distension (3750 ml urine), urinary obstruction from enlarged prostate causing paralytic ileus increasing aspiration risk. The coroner found medical care at hospital appropriate. Key lessons: mental health teams did excellent work monitoring him; earlier GP engagement and physical health assessment might have identified the obstructive uropathy and gastrointestinal dysfunction contributing to aspiration risk; multidisciplinary approach needed for patients with severe mental illness and declining physical health.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- paralytic ileus secondary to obstructive uropathy
- markedly enlarged prostate causing urinary obstruction
- profound malnutrition and weight loss from 3-week religious fasting
- bladder distension with urinary retention (3750 ml)
- chronic pyelonephritis
- iron deficiency anaemia
- acute psychosis with religious delusions
- long-standing schizophrenia
- poor compliance with antipsychotic medication
- physical deterioration and functional decline
- social isolation and homelessness risk
- lack of general practice follow-up for 5+ years
Full text
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