Coroner's Finding: Rosendale, Dwayne Edward

36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of gastric contents and sleep apnoea

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.