The report investigates the medical background and circumstances surrounding the death of a severely retarded adult male who was a resident of a community developmental center in New York State. It illustrates the complex medical, legal, and ethical issues involved in medical decision making on behalf of persons unable to provide informed consent. The report chronicles the patient's institutional history, the medical treatment he received at two different hospitals outside the developmental center, communication with a family member, postoperative condition and treatment, and autopsy results. A mental hygiene medical review board concluded that the condition of the patient while in residence at the community facility deteriorated significantly over the course of a few years. Decisions involving consent for major medical procedures were also questioned. Among seven review board recommendations were the following: (1) the Office of Mental Retardation and Developmental Disabilities should clarify, through specific policy statements and guidelines, who should be consulted with respect to medical care decisions on behalf of an incompetent client; (2) the community developmental center should evaluate its treatment planning process to assure that periodic multidisciplinary treatment reviews address all client needs and assess any observed changes in clients. (JW)