He was diagnosed with dementia secondary to neurosyphilis in 2006 and had a history of taking food that did not belong to him.
Mr Frugtniet Marco Robert, 47, who was a resident at the Apex Harmony Lodge, which is a home for people with dementia, choked on a fishball last September and died.
Yesterday, State Coroner Marvin Bay found that his death was accidental and that it was a "truly unfortunate misadventure".
He said it was likely that Mr Robert had sneaked into a servery room at the home while nursing aides were engaged in their duties and helped himself to the fishball meant for staff members.
Said Coroner Bay: "To avoid detection, he likely forced his illicit bounty down his throat without taking the time to properly masticate or chew his food.
"He had been rendered unable to breathe as a result of the inextricable situation of the fishball."
Mr Robert had stayed at the Pasir Ris Walk home since 2010, when his wife admitted him because of difficulties managing his behaviour associated with personality changes. This is following his disease, which is a slow progressive, destructive infection of the brain and the spinal cord.
While there, he enjoyed a full unrestricted diet and had no history of choking or difficulty in swallowing. He was also able to feed himself independently.
At around 10.45am on Sept 16, a nursing aide found Mr Robert motionless in a chair in a recreational room.
Workers at the home performed cardiopulmonary resuscitation on him, but to no avail. Paramedics pronounced him dead about 30 minutes later.
In his findings, the coroner said that none of the nursing aides witnessed Mr Robert's actions between 9.30am and 10.45am that day.
The scene was also not captured by closed-circuit television camera as the system installed had fallen into disuse and had not been working since at least 2013.
Coroner Bay said that based on the evidence uncovered, there was no basis to suspect foul play.
He said: "There are no injuries on (Mr Robert) to suggest mistreatment by the nurses.
This article was first published on Apr 8, 2015.
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