The incident has prompted Otago-Southland Coroner David Crerar to send his findings on the death to Minister of Housing Maurice Williamson with a recommendation he consider changing the building code to address the issue of toilet doors, particularly in areas like an emergency department, having external access through inward opening doors.
Oamaru Hospital has already started to change its toilet doors to provide an outward-opening portion which can be used by staff if a similar incident occurred.
Dean Roland Smith, of Oamaru, who also suffered from epilepsy, was admitted to the hospital's emergency department on October 10 at 7.55am.
He died about 1.10pm after collapsing about 12.15pm and being trapped in the toilet.
He collapsed with his head against the inward-opening door.
Hospital staff could not force their way in because they feared they could severely injure his neck, head or spine.
A builder from a neighbouring building site used power tools to cut away half the door so Mr Smith could be attended by a doctor and removed from the toilet.
Mr Crerar found Mr Smith died from asphyxia during a convulsion when he was trapped in the toilet, delaying appropriate resuscitation efforts by medical staff.
Mr Smith's sister, Heather Diann Vincent, of Oamaru, said her brother was handicapped from a significant brain injury when he was 3.
He also suffered from epilepsy.
About 7.30am on October 24 he was taken by ambulance to Oamaru Hospital, where he was treated and medication administered.
While being treated, he wanted to go to the toilet and was assisted by Mrs Vincent in a small public toilet at the emergency department.
She said the public toilet was very small and she had difficulty helping her brother.
Nurse Sharief Kamel said that about noon, Mr Smith wanted to go to the toilet again.
About 12.15pm, Mr Kamel heard "a loud crash" from the toilet and went back, asking Mr Smith if he was all right.
Mr Smith did not answer him.
Mr Kamel found he could not open the door.
He eventually managed to push it ajar about 10mm.
In a mirror, Mr Kamel could see Mr Smith lying on the floor with his head against the door.
Mr Kamel estimated Mr Smith was trapped in the toilet for about 30 minutes.
Attempts were made to revive him but were discontinued when it was established there was no brain activity.
Mr Crerar is requesting further information from Oamaru Hospital on some issues raised during yesterday's inquest, which he directed not be published until the information was received and he issued his written decision.
He also said he had made inquiries with the Waitaki District Council about the toilet door and was told it complied with the building code.
However, Mr Crerar believed that was flawed - particularly in areas like a hospital emergency department.
In such areas, it was more likely a patient could collapse while using a toilet, so the door should have some access opening outwards.
