Inquest into the Death of Andre Walter BOND
Deceased
Andre Walter BOND
Demographics
42y, male
Date of death
2019-05-14
Finding date
2021-05-10
Cause of death
Upper airway obstruction (choking) in an obese man with atherosclerotic heart disease and schizophrenia
AI-generated summary
Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently discharged from psychiatric inpatient care on a Community Treatment Order with a stable medication regimen including quetiapine, sodium valproate, paroxetine, and olmesartan. The coroner found his mental health supervision, treatment, and care during inpatient admission and community management to be appropriate and reasonable. Death was determined to be accidental. The coroner noted that while intensive personalised community interventions (such as individual placement support) might theoretically benefit patients with schizophrenia, service resources did not allow such intensive intervention. No clinical errors or failures in supervision were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- Severe obesity (BMI in very severely obese category, weight 183 kg)
- Atherosclerotic heart disease with cardiomegaly
- Possible non-compliance with some medications at time of death (paroxetine, sodium valproate, olmesartan not detected at post-mortem)
- Eating alone while consuming steak and vegetables
Coroner's recommendations
- The coroner noted that while personalised interventions and individual placement support have been shown in research to benefit patients with schizophrenia, service resources did not allow such intensive intervention. This was not framed as a formal recommendation but as an observation about resource constraints.
Full text
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