Coroner's Finding: TARNOWSKI Marek Tomasz

33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphine, diazepam and gabapentin), morbid obesity and probable aspiration of gastric contents

A 33-year-old man with chronic back pain, depression, morbid obesity and sleep apnoea died in psychiatric custody from respiratory failure due to mixed drug toxicity and probable aspiration. He was heavily medicated with CNS depressants (amitriptyline, oxycodone, morphine, diazepam, gabapentin) for pain and depression management. Found unresponsive while sleeping on a mattress without his CPAP machine, he had vomited prior to collapse. The coroner found no single preventable factor, noting that insisting on CPAP use might have caused problems given the vomiting, and that the medication regimen was carefully supervised during his first admission. The death resulted from a tragic combination of chronic pain requiring heavy medication, obesity, sleep apnoea, and probable aspiration—a complex interplay of factors rather than clinical error.