Coroner warns of misusing prescription drugs after young woman dies

The dangers of misusing prescription drugs have been highlighted by the death of a young Dunedin woman, a coroner says.

By Anna Sargent of RNZ

Wynter Horrell, 20, died at her South Dunedin home in December 2021 after diluting her prescribed tramadol with water and injecting the opioid painkiller into her bloodstream using her portacath implant.

In findings published on Thursday, Coroner Mary-Anne Borrowdale criticised the initial police investigation into the unexplained death, labelling it superficial.

The coroner's inquiry focused on establishing who did the injection, the reason why, and if Horrell's death was preventable.

Borrowdale found Horrell's death was accidental.

She had deliberately chosen to inject her medication, and neither she nor her partner knew it could be life-threatening.

"This was a death by misadventure," Borrowdale said.

"I appreciate that this inquiry has been long and demanding, and I am grateful for all efforts that have been made to seek answers to Wynter's sudden and untimely death."

Horrell's mother, Aimee Horrell, told RNZ her daughter's death left an immense void in her life that would never be filled.

"Losing Wynter unexpectedly at just 20 years of age has been devastating for our family. She was a deeply loved daughter, granddaughter, niece, cousin and friend - kind, caring, vibrant and full of hopes and dreams," she said.

"We are grateful to the coroner for the time and care taken to investigate the circumstances surrounding Wynter's death. While this report cannot bring her back, it does provide some answers in helping us to attempt to better understand what happened. The unanswered questions and failings we will carry with us for the rest of our lives."

Borrowdale said Horrell had many long-standing medical problems and had been diagnosed with cerebral palsy and Crohn's disease, and suffered non-epileptic seizures.

"Nonetheless, Wynter had a positive and outgoing attitude and did well at school, becoming head girl of her Oamaru school in Year 8," she said.

"Wynter completed high school by achieving an NCEA Level 3 qualification and enrolled in an Otago Polytechnic occupational therapy course taught in Dunedin. She was described as thriving at this period, and excited for her future. She was fully mobile and participating in all aspects of life despite her medical setbacks."

Horrell and her partner, Taylor Stewart, moved into a flat together in early 2021.

Her health sharply deteriorated during the year.

She was prescribed an extensive list of medications, including tramadol in capsules to be swallowed orally, by the time of her death in December.

Horrell told Stewart, in the days before she died, clinicians advised her to dilute and inject her tramadol through her portacath for pain relief.

Horrell's doctors denied that, and Borrowdale accepted their evidence.

"No hospital staff member gave Wynter the advice to dilute and inject her tramadol, and it would have been professionally incompetent and irresponsible for them to have done so. It is unclear how Wynter came to the decision to administer tramadol through her portacath," Borrowdale said.

Horrell needed further medical supplies to inject the solution.

"She already had syringes, but she needed gripper needles. She obtained these, upon request, from a clinical nurse specialist at the hospital by misleading the nurse into thinking that she had been issued with the needles before, that she had been trained to self-administer IV medicines at home and that her GP had prescribed the necessary drugs. These representations were untrue."

Stewart helped Horrell inject her medication.

He called 111 early on 2 December when she became short of breath, but did not tell the calltaker about the injected tramadol.

By the time an ambulance arrived at their home, Horrell was unresponsive and could not be resuscitated.

Police assumed Horrell's death was natural and did not protect the scene. That was a mistake, Borrowdale said.

"Much later, post-mortem evidence showed that Wynter had died from the complications of encapsulated prescription medication having been injected into her bloodstream. The tiny particles in the mixture blocked many of Wynter's blood vessels, preventing blood flow through her lungs and causing her heart to fail."

An inquest was held during two hearings in March and October 2025.

The cause of Horrell's death was known, but the circumstances were less clear and heavily contested, Borrowdale said.

"This was partially because Mr Stewart's evidence was often contradictory, and I found it to be unreliable in some key respects. In addition, I found that there were unhelpful shortcomings in police initial inquiries," she said.

However, she did not find any person or organisation failed Horrell by failing to anticipate she might misuse her medication.

"The prescription of tramadol to Wynter contributed to her death because misuse of that drug caused her lethal condition. But Wynter's GP was not wrong to prescribe tramadol for her pain. He was entitled to expect that Wynter was taking her medications in orthodox ways and had no awareness that she may not do so," Borrowdale said.

"There was a very small window of time between Wynter's first misuse and her death. Prior to 30 November there was no suggestion that Wynter might misuse her tramadol, barely 48 hours later she had died. There was no opportunity for Wynter's misuse to be discovered by practitioners even if there were indications pointing to it (which there were not)."

Stewart materially assisted Horrell with the injections and without his help her death would likely not have occurred, Borrowdale said.

However, she was satisfied it was Horrell's idea.

"Mr Stewart understood that Wynter wished to take the tramadol intravenously for better or quicker pain relief.

"It is likely that Wynter took or received one or more injections on 2 December 2021 between 4.30am and 5.30am when Mr Stewart called 111. It is highly likely that these injections were much more concentrated than those that had previously been administered. At this point Wynter's chest pains and shortness of breath became overwhelming and these effects could not have been reversed even if Mr Stewart had mentioned the tramadol injections to the 111 calltaker or paramedics."

The initial police investigation was underwhelming, Borrowdale said.

"It was insufficiently enquiring of police to assume that Wynter's death was natural and to fail to gather evidence of all the items and from all the people at the scene for the assistance of the coroner to whom the death had been reported," she said.

"I accept that at the scene police had no knowledge of the unapproved tramadol injections. I also accept that police would have approached the scene and witness investigations quite differently and more forensically had they known of this.

"However, the fact remains that the investigation into this unexplained death was superficial at best. Its effect has been to significantly protract my investigation and to leave unanswered key aspects of Wynter's death including (vitally) whether there were liquids, syringes, gripper needles and the like at the scene but undocumented."

Inspector Shona Low said police were committed to learning from the lessons identified by the coroner.

"Police instructions for attendance at sudden deaths has since been strengthened to include clear guidance on the involvement and attendance of the Criminal Investigation Branch at complex and unexplained deaths," she said.

Borrowdale also warned about the dangers of misusing medication.

"It is recognised that some people with chronic serious pain will not take their medications as prescribed and may find other modalities for their medications to have quicker effect. However, it is extremely dangerous to inject intravenously any drug not formulated for intravenous use such as an oral tablet or capsule. Oral pills pass through the stomach, which has acids to dissolve them so that the drug can be absorbed.

"When crushed or diluted oral tablets or capsule contents are injected intravenously their microscopic ingredients can obstruct the blood vessels preventing oxygen reaching the blood. This leads to embolism, irreversible heart failure and death within a very short space of time.

"This tragedy demonstrates that further information can and should be provided to patients with intravenous access devices and I commend Health NZ for the changes it has made to ensure that this happens."

Health New Zealand said it had implemented new processes and strengthened safeguarding measures to reduce the risk of a similar death in the future.