Paramedics rushed to the home of 20-year-old Wynter Shirley Horrell and her boyfriend Taylor Stewart early on December 2, 2021, but were unable to revive her.
Police who attended quickly wrote it off as the natural death of a young woman with long-standing, complex medical issues and a pathologist put it down to the complications associated with taking multiple medications.
In her lengthy findings released this week, Coroner Mary-Anne Borrowdale said they were both wrong.
She also said Mr Stewart gave an ‘‘incomplete, inconsistent and self-serving series of accounts of his actions’’ leading up to the tragedy, which were designed to minimise his role.
By mid-2022, the recording of the 111 call made by Mr Stewart was obtained and Ms Horrell could be heard in the background yelling.
‘‘I’m struggling to breathe ... help me.’’
The coroner said that seemed ‘‘highly unusual’’ for a person who was supposedly dying from a drug overdose.
Members of Ms Horrell’s family also raised concerns about Mr Stewart’s disclosures that she had dissolved her tramadol medication in water and injected it.
Despite the practice only starting days before her death, he did not disclose it to emergency services or police when interviewed that day.
Mr Stewart attributed it to being in ‘‘panic mode’’ and said he did not think it could have caused Ms Horrell’s death.
The omission, the coroner said, was ‘‘striking’’.
A subsequent review of the evidence by a second forensic pathologist — Dr Judy Melinek — detected microscopic tramadol crystals blocking blood vessels in lung samples taken during the postmortem.
Mr Stewart told the inquest they would dissolve six of Ms Horrell’s prescribed painkillers in two litres of water and then inject the solution through a portacath — an implanted device placed under the skin to provide long-term, reliable access to a patient’s bloodstream.
He admitted involvement in the preparation of the concoction, but said he did not administer it.
Mr Stewart said he last saw Ms Horrell inject the solution two days before her death and noticed some of the mixture missing when he returned from work the following day, assuming she had self-administered.
But, according to the medical experts, that did not explain the young woman’s demise.
Toxicologist Dr Leo Schep said the level of tramadol in Ms Horrell’s system could not be explained by the weak infusions.
‘‘Wynter must have received a very significant, concentrated dose of tramadol immediately before going into heart failure,’’ he said.
Dr Melinek agreed.
Mr Stewart said he woke shortly after 5.30am on December 2, 2021, to hear his girlfriend struggling to breathe, so called emergency services.
He later changed his story, telling Ms Horrell’s mother months after the incident that he got up to use the toilet, which sent his partner into a panic, leading to her breathlessness.
So who gave her the fatal dose of Tramadol that morning?
The coroner said there were three possibilities: Ms Horrell self-administered; the couple were both involved; or Mr Stewart did it.
‘‘I have no way of knowing which of these possibilities is correct,’’ the coroner said.
‘‘The evidence does not allow this to be determined.’’
The major reason for the evidential insufficiency came down to the actions of police in the aftermath, the inquest heard.
The coroner described the investigation as ‘‘superficial at best’’.
Photos were only taken of medication that was in plain view and officers failed to interview all those who were present at the scene.
A sergeant said he did not request or view any electronic devices from the parties involved because he ‘‘didn’t have the intuition’’.
‘‘Police did nothing to protect the scene.
‘‘They permitted members of Mr Stewart’s family to begin tidying the house — inevitably altering the scene — while they were there,’’ the coroner said.
‘‘[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.’’
While she was satisfied Mr Stewart actively assisted with the tramadol injections and ‘‘misled’’ the inquiry at times, she concluded there was no intent involved.
‘‘This was a death by misadventure,’’ the coroner said.
No recommendations were made.
