From birth, Wynter Horrell made a habit of defying the odds.
She was born on August 2, 2001, 13 weeks premature.
There were complications with her lungs, kidneys and liver, meaning she required oxygen for the first 14 months of her life.
At 3, she was diagnosed with cerebral palsy and underwent several operations.
Problems with Ms Horrell’s jaw led to it being wired shut for a lengthy period and stomach pains led to a diagnosis of Crohn’s disease.
Her symptoms included weak arms, sleeplessness and mild learning difficulties; the list went on.
Her health issues, though, were overridden by her ‘‘positive and outgoing attitude’’.
Ms Horrell was named head girl at her Oamaru school in year 8 and, in November 2019, she received one of the inaugural prime minister’s vocational excellence awards.
Her principal described her as ‘‘a motivated and resilient student’’ as she prepared to head off to Dunedin for a polytech course.
But a little over two years after the award ceremony, Ms Horrell died in her South Dunedin flat, a ‘‘death by misadventure’’, Coroner Mary-Anne Borrowdale said in her written findings released this week.
The coronial inquiry was held over seven days last year and while it answered how the 20-year-old died, the circumstances were far less straightforward.
For that, there were two culprits.
Police, who attended Ms Horrell’s home on the morning of December 2, 2021, swiftly determined the death was natural.
‘‘There was nothing at the time indicating that there was anything untoward in ... the young lady’s death at the time.
‘‘We knew that she had multiple illnesses and things like that,’’ a sergeant told the inquest.
Officers did not secure the scene, did not itemise all the medication at the home, did not interview all those present and did not seek to analyse the electronic devices of the parties involved.
‘‘Its effect has been to significantly protract my investigation, and to leave unanswered key aspects of Wynter’s death,’’ the coroner said.
The second confounding aspect was the testimony of Ms Horrell’s boyfriend Taylor Stewart with whom she lived in a South Dunedin flat.
The coroner described his evidence as ‘‘often contradictory, and ... unreliable in some key respects’’.
‘‘The inquiry faced one implacable difficulty: that on 2 December 2021 Wynter and her partner, Mr Stewart, were alone at home.
‘‘Only Mr Stewart is alive to tell us what happened within their home before Wynter’s death,’’ she said.
In 2019, Ms Horrell met Mr Stewart, a Dunedin retail assistant, via a dating app.
At the start of the following year, she started an occupational therapy course at Otago Polytechnic and moved into halls of residence.
Ms Horrell was ‘‘delighted’’ by her newly found independence and graduated in December 2020.
She moved in with Mr Stewart in early 2021 and decided to ‘‘take time out’’ for her health rather than immediately take the plunge into the workforce.
Ms Horrell’s array of symptoms were worsening.
She had been experiencing non-epileptic seizures, sometimes several a day.
Attending Dunedin Hospital’s Pain Clinic, she wavered between hypotheses.
Perhaps it was the seizures causing the discomfort; maybe vice-versa.
Without full access to her medical file, Dr David Jones’ conclusion was necessarily brief, and sad.
‘‘[This is] not one pain, this is a multitude of pains,’’ he wrote.
During his session with Ms Horrell, also attended by her boyfriend, he noted an ‘‘unveiled animosity’’ between the couple when discussing her seizures.
Dr Jones offered her access to the clinic’s pain management programme, but never heard from her again.
The real spiral began in January 2021, when Ms Horrell fell while showering.
She took to using a wheelchair, but the extent of her injuries was unclear. Clinicians found no structural damage to her spine, but she told friends she was ‘‘paralysed’’.
An occupational therapist noted Ms Horrell’s resistance to rehabilitation.
Ms Horrell’s family, who had previously been integral supports when it came to her medical issues, were suddenly out of the loop and Mr Stewart became her de-facto carer.
There were frequent trips to the hospital’s emergency department, which resulted in the creation of an ‘‘unusual document’’ known as a care plan, the coroner said.
Ms Horrell was unaware of its existence, but it gave medical professionals a reference point in dealing with her multiplicity of complaints.
‘‘Wynter often misinterprets her symptoms and catastrophizes her presentation. She may present as seeking specific medications, investigations or supports,’’ one notation said.
The coroner said Ms Horrell often gave unreliable or incomplete accounts about her symptoms, advice and treatment but did not do it to consciously mislead others.
There was a growing desperation for Ms Horrell to alleviate her myriad health concerns.
She had a portacath implanted in June 2021 — a small device installed under the skin of the upper chest — to simplify regular infusions and allow ready access to a vein.
Four months later, she had an appointment with the hospital’s gastroenterology department to discuss surgery to remove her colon, rectum and anus.
Ms Horrell was adamant it was the only option but specialists voiced their concerns about the drastic procedure.
She said she was unable to eat, could not swallow her medication — but that was contradicted by messages she was sending to Mr Stewart during that period requesting specific food.
On November 29 that year, just three days before her death, came a ‘‘noteworthy’’ development, the coroner said.
Ms Horrell contacted her GP specifying drugs, formulations and quantities that she believed she needed.
The doctor described it as ‘‘a real red flag’’ and no such prescription was made.
So Ms Horrell called the hospital.
Speaking to a nurse, she requested specific needles that would allow her to access her portacath.
It sounded legitimate and, without access to Ms Horrell’s care plan, the nurse packaged them up.
Over those final days, Mr Stewart’s role became hazy.
On one account, he said he had picked up the needles and recalled the weight of the bag being light, on another he said he had no recollection.
‘‘I believe that Mr Stewart’s fluctuating evidence arises through a desire to minimise his involvement,’’ the coroner said.
And it was not the first inconsistency in his statements.
He said Ms Horrell told him she had been advised by someone at the hospital to dilute her tramadol and inject it through her portacath.
Six tablets should be diluted in two litres of water and injected ‘‘whenever she felt she needed it’’, Ms Horrell reportedly told her partner.
The role he played in the infusions was the subject of intense scrutiny at the inquest.
Mr Stewart initially told police he made up the mixture but later recanted, saying he was ‘‘overwhelmed’’ by the stress of being interviewed.
The coroner was scathing of his varying versions.
‘‘Mr Stewart has cast about widely in search of explanations for Wynter’s actions that exculpate him and implicate others, even when those explanations make little sense,’’ she said.
Mr Stewart’s account of the day before the tragedy raised more questions.
First, he told police he had left work at lunchtime because Ms Horrell was short of breath and he comforted her until her condition improved that evening.
At the inquest, though, Mr Stewart said he arrived home at 5pm and questioned why she had only used a quarter of the tramadol concoction.
‘‘Wynter said that she was scared. She said she didn’t want to take it any more,’’ he said.
Under cross-examination, Mr Stewart found a middle ground, explaining he may have gone home for lunch, but later completed a full day of work.
‘‘I am not confident that Mr Stewart now has any reliable recollection of these events,’’ the coroner said.
‘‘Certainly, he is in my view unable or unwilling to accurately give evidence about them.’’
At 5.35am on December 2, 2021, Mr Stewart called 111.
In the recording, Ms Horrell could be heard in the background.
‘‘I’m struggling to breathe,’’ she said.
‘‘Help me.’’
Emergency services were on the scene within 10 minutes, but she was unresponsive.
Mr Stewart never mentioned to the call-taker or the paramedics that Ms Horrell had received the tramadol-solution injections, nor did he raise it with police who attended in the aftermath.
He claimed it was a product of his distress.
The coroner had a different explanation.
‘‘To my mind, he was worried that the tramadol might have been relevant to Wynter dying, so did not mention it.
‘‘This level of wilful blindness is consistent with my earlier conclusion that the many variations in his evidence have arisen from an effort to distance himself from events,’’ she said.
The pathologist who conducted the postmortem put the death down to ‘‘polypharmacy toxicity’’ — a drug overdose.
Ms Horrell was taking nine prescribed medications at the time of her death.
But it did not wash with her family.
They told the coronial inquiry they had heard Mr Stewart speak about the tramadol infusions.
Ms Horrell’s mother Aimee even arranged a meeting with Mr Stewart at St Clair, 10 months after the death, which she secretly recorded.
He told her he was ‘‘not allowed’’ to give his girlfriend chest compressions because of the potential damage to her spine, something the coroner called ‘‘patently false’’.
The information about the tramadol led to a second pathologist’s involvement.
Dr Judy Melinek discovered microscopic crystals blocking the blood vessels in Ms Horrell’s lungs, leading to heart failure.
‘‘There must have been a dose or doses imminently before Wynter’s death,’’ she said.
Toxicologist Dr Leo Schep concurred.
The level of tramadol in her system was inconsistent with the few injections of weak solution described by Mr Stewart.
‘‘Wynter must have received a very significant, concentrated dose of tramadol immediately before going into heart failure,’’ he determined.
But that did not accord with Mr Stewart’s version of events.
Ms Horrell would have had to get out of bed in the early hours without waking him and, made the mixture herself and injected it.
Ultimately, who delivered the final, fatal dose was an impossible question for the coroner.
‘‘The evidence does not allow this to be determined,’’ she said.
Police attended the scene shortly after being informed of Ms Horrell’s death, but quickly reached the conclusion it was a simple medical event.
A natural death.
The coroner exposed the shortcomings in the police’s approach.
‘‘[Ms Horrell] was a very young woman.
‘‘She was alone at home with her intimate partner when she died.
‘‘Various restricted drugs were found around her.
‘‘Although she had illnesses, none were sufficient to account for her sudden death.
‘‘Her bereaved family were utterly shocked by her death.
‘‘At the very least, police ought to have been open-minded to the possibility that drugs or non-accidental harm were implicated in Wynter’s sudden death.’’
Police contacted Ms Horrell’s GP to see if he would certify her death.
He declined to do so, as it was ‘‘totally unexpected’’.
The documentation of drugs found at the scene only extended to what attending officers could see.
They did not seek any other medication, and the inquiry heard it was later disposed of by Mr Stewart’s family.
Vitally, police found no jug of liquid at the scene and Mr Stewart said he was unaware of what happened to it.
‘‘Police placed a high degree of reliance on Mr Stewart’s evidence, although he was her intimate partner and the only person who was with Wynter when she died,’’ the coroner said.
Police did not call in detectives to attend, nor did they freeze the scene as they would for a suspicious death.
The coroner said she was satisfied Mr Stewart ‘‘actively assisted’’ with Ms Horrell’s scheme to administer the tramadol solution.
While his evidence was inconsistent, she was confident there was no ill intent.
‘‘Neither Wynter nor Mr Stewart knew that diluting and injecting her tramadol could be life-threatening.
‘‘As such, this was a death by misadventure,’’ the coroner said.
It was unclear how Ms Horrell had come to the decision to inject the solution but the coroner said it was certainly not at the advice of any medical professional.
While the needles used to access the portacath were incorrectly provided, she said there was no person or organisation who failed Ms Horrell.
Health New Zealand Te Whatu Ora had since made changes to electronic systems and the way in which such patient requests were dealt with, the inquest heard.
The coroner made no recommendations, but stressed pills or capsules should be swallowed and never crushed or dissolved for injection.
‘‘[Mr Stewart] could have tried to check with clinicians when he thought the scheme was ‘weird’, ‘stupid’ and ‘odd’.
‘‘He did not do so.
‘‘Seeking advice could have prevented Wynter’s death,’’ she said.
Aimee Horrell told the Otago Daily Times the loss of her daughter had been ‘‘devastating’’ for the family.
‘‘She was a deeply loved daughter, granddaughter, niece, cousin and friend — kind, caring, vibrant and full of hopes and dreams,’’ she said.
‘‘Her passing has left an immense void in our lives that can never be filled.’’
Mrs Horrell said she hoped the case led to meaningful change to prevent other families experiencing such pain.
‘‘While this report cannot bring her back, it does provide some answers in helping us to attempt to better understand what happened,’’ she said.
‘‘The unanswered questions and failings, we will carry with us for the rest of our lives.’’
