A coroner has found a care home provided inadequate care to a man who died after eating a large amount of food.
Paul Douglas Thompson, who was 37, died in Hawkes Bay Hospital in April 2013 from complications caused by eating eight burger buns, three loaves of bread and 24 muesli bars.
Coroner Carla na Nagara said Mr Thompson's underlying condition of Prader Willi syndrome, a rare congenital disorder which causes obsessive eating, contributed to his death.
On 7 August, he found keys to the freezer at the Idea Services care home in Napier, where he lived.
After eating the large amount of food, he was up all night going to the bathroom and vomiting, but his carer did not seek medical treatment.
At the time, his carer reported that at the beginning of her shift Mr Thompson was behaving normally and it was not until later that night he began to appear unwell.
"He said he had an upset tummy, he messed himself, his bed and in the hallway - he continued to do this all night, each time I asked him if he was all right, he said he was getting better."
It was not until the following day when he went to his day programme, at about 8.30am, that the decision was made to take him to a doctor.
His service worker Karen Brookes said he was struggling to walk and "sort of waddling".
"His stomach was huge, it sounded like he was having trouble breathing and his face was pale."
Mr Thompson went to the doctor who sent him for blood tests and an urgent x-ray of his abdomen.
After the x-ray, he was taken back to his day programme where he continued to vomit and feel unwell.
His carer took him back to the doctor's where an ambulance was called and Mr Thompson was taken to hospital.
While having a CT scan, Mr Thompson went into cardiorespiratory arrest and died shortly after 4.30pm.
Mr Thompson was taken to hospital the next day, where he went into cardiorespiratory arrest and died.
The Coroner said Idea Services did not provide adequate care and failed to respond to his constant toileting and soiling.
"I do not consider these inadequacies led to Paul's death, but they are important matters in the wider factual matrix of his death."
She said Idea Services was expected to address the issues of security and care and provide better training for staff.