INMATE DIES AFTER METHADONE DOSE

The Christchurch coroner yesterday adjourned an inquest into the death of
an inmate unwittingly given too high a methadone dose by a prison nurse.

The inquest heard that the death of Neroli May Cuthbert, believed to be the
first of its kind in New Zealand, had led to a stricter regime for managing
opioid-dependent inmates.

Cuthbert, 49, was on remand at Christchurch Women's Prison for the alleged
wholesale supply of her morphine sulphate tablets (MST) prescription in
July 2000.

Police said she began receiving MST for chronic back and neck pain two
years earlier. The Waimate woman was also deaf and suffered from epilepsy.

The inquest heard that a preliminary health check was done of Cuthbert, who
readily admitted she was on prescribed MST.

The prison phoned Cuthbert's Dunedin GP to confirm her medications. MST had
certainly been prescribed in the amounts and strength relayed by Cuthbert.

But the doctor also expressed "some concern" that the tablets were "being
diverted and not taken regularly". The warning was noted by a prison nurse.

Challenged about her use of MST, Cuthbert explained she had been taking
"more than her prescribed doses at times to get rid of them", so they could
not be taken or stolen by someone close to her.

Accordingly, medical staff at the prison sought advice on an appropriate
methadone dose for Cuthbert. MST was not available in prison because of
fears it could be smuggled to other inmates.

At 6.30pm on July 21, 2000, Cuthbert drank 120mg of methadone - the
equivalent to the MST prescribed to her daily - and washed it down with a
cup of water.

The nurse who gave it to her said she repeatedly checked that Cuthbert was
on 240mg of MST per day.

Ten hours later Cuthbert was found dead in her cell, having choked on vomit.

In a written report presented at the inquest yesterday, pathologist Martin
Sage said Cuthbert was "very likely to have much less tolerance to
methadone than would be indicated by her prescription history" and that the
initial 120mg dose was "inappropriate".

Prisons inspector Greg Price said Cuthbert had given what was considered a
reasonable explanation for her GP's doubts about the MST use.

He said Christchurch Women's medical staff had no reason to suspect the
drug supply charges related to Cuthbert's own medication. That level of
detail simply was not provided to the prison.

That had now changed, with the introduction in April 2001 of a more careful
and considered methadone regime at Canterbury Prisons. The new protocol had
also been distributed nationally.

Christchurch Coroner Richard McElrea ruled the death accidental.

He adjourned the inquest to consider calling further medical evidence.