Rob Kidd charts the course of the case which has seen the actions of medical staff placed under intense scrutiny.
A couple of weeks after being imprisoned, Boyd Cuttance told a nurse his head was "killing him".
Tragically, he was almost right.
More specifically it was what was inside his head that was the problem — a rare meningitis caused by an invasive soil-borne fungal infection, most likely picked up during his work in a nursery.
Mr Cuttance’s stay behind bars was due to last two and a-half years, but the debilitating headaches that had plagued him in the weeks leading up to his incarceration continued.
After 48 days at the Otago Corrections Facility — and 27 interactions with medical staff — the 44-year-old was taken to Dunedin Hospital.
For 72 days doctors desperately attempted to uncover the source of Mr Cuttance’s illness, but it was only when he died on March 28, 2012 that the mystery was solved.
His mother Elizabeth, a trained nurse, visited him on the day he was admitted to hospital and found him weak, vomiting, his speech "all jumbled and slurred".
She was amazed he had not been transferred sooner.
"He was so seriously ill that I could not believe that no action had been take to have him referred to the hospital. I believe that it was only after my intervention that action was finally taken," Mrs Cuttance wrote to coroner David Crerar after he released his provisional findings in 2013.
In a written decision in 2015, the coroner was critical of the care the inmate received while in prison.
"The evidence proves that Boyd Cuttance was, from the time he was admitted to OCF, very ill. He was terminally ill. His headaches were severe and these headaches resulted in physical symptoms, beyond those of normal headaches, which could, or should, have been observable by a medical professional," Mr Crerar said.
"Although it has to be accepted that the causes of the illness of Boyd Cuttance were obscure, the severity of his symptoms and the significant number of presentations, ought to have been a warning to those responsible for his medical care ... OCF management and the nurses at the health centre were wrong in thinking that the taking of blood tests, the provision of neurological tests, observing, reporting on symptoms and providing pain relief medication for the headaches was appropriate healthcare."
Mrs Cuttance was upset that Corrections continued to defend its nursing staff and the contracted GP who assessed her son and she believed they had minimised the symptoms Mr Cuttance exhibited to absolve themselves of blame.
The coroner’s opinion was not vindication enough.
In September last year, Mrs Cuttance took the fight to the Dunedin District Court.
Because her claim was brought more than six years after her son’s death, the Limitation Act prevented the award of financial damages.
That did not deter her.
She sought a series of declarations, essentially inviting the court to determine those who had been entrusted with Mr Cuttance’s medical care had been negligent.
"The degree of negligence of the prison medical staff dealing with Boyd was outrageous and amounted to subjective recklessness. The staff would have been aware that by failing to respond to Boyd’s symptoms and complaints there was a serious risk to health and potentially to his life," Mrs Cuttance said in a statement of claim.
The crux of the case hung on one point.
"The fundamental question is whether the prison medical staff, and Dr X in particular, should have referred Boyd to a specialist much earlier than his admission to hospital on 15 January 2012."
It was not whether the care was below the standard of best practice but whether it fell below the threshold of a "reasonable standard of care".
From 1987-2006, Mr Cuttance racked up a series of convictions, generally related to his alcohol use.
After that, however, the drinking slowed down and he turned a corner.
He had work in the horticultural industry and his life had more structure.
Then the headaches began.
By the start of 2011 they had worsened. Mr Cuttance upped his alcohol consumption just to sleep and gain some respite from the nagging pain.
While he had been in trouble with police, his mother said what happened on June 18, 2011 was completely "out of character".
Mr Cuttance was refused entry to the Lake Waihola Cafe and Bar and was forcibly removed to the car park after an altercation with the manager.
He then took a container of petrol from his car and walked along a line of vehicles outside the restaurant, pouring petrol over nine of them before setting fire to the last in the line.
Mr Cuttance drove out of the car park and stopped 200m away while those at the venue used an extinguisher to douse the blaze.
After extinguishing the fire, the bar manager challenged the arsonist, who had returned to the scene holding two petrol containers.
Mr Cuttance responded by splashing fuel on the man and flicking a cigarette lighter.
He was tackled to the ground and restrained until police arrived.
Mr Cuttance was granted bail, and his headaches worsened.
Over a single week in October 2011, he attended Dunedin Hospital three times reporting extreme pain and, on the final appearance, vomiting, tingling limbs and blurred vision.
A CT scan revealed an infected sinus and he was prescribed painkillers, anti-inflammatories and antibiotics.
A month later, he appeared in the Dunedin District Court where he was sentenced to two and a-half years’ imprisonment.
His mother was so worried about his physical state that she called the prison the next day to ensure he would have access to the correct medication.
Mr Cuttance saw the contracted GP that same day. His three consultations with the doctor were placed under the microscope during last year’s hearing.
Despite opposition by Mrs Cuttance, the doctor’s name was suppressed by Judge Kellar because there was a "real risk of significant damage" to her professional reputation.
At their first meeting Dr X noted Mr Cuttance’s respiratory rate and blood pressure were normal and he had no aversion to light.
She prescribed Panadol and Nurofen and continued the anti-anxiety medication he had previously used.
The woman told the court at last year’s hearing that Mr Cuttance described the pain as being "heaps better" and she believed he might have been suffering tension headaches.
Things appeared to settle for a couple of weeks but the symptoms did not retreat for long.
One nurse noted Mr Cuttance had said "his head is killing him" and the next day he was reported as crying in his bunk.
"I feel terrible, pain all over my head, like I’ve had before, it’s getting worse today. I usually go to A&E and they hydrate me. I think I need an anti-inflammatory, I’m dizzy," the prisoner told them the next day.
The second consult with Dr X took place the next day on December 20, 2011, and during it Mr Cuttance said the on-off pain could be "excruciatingly painful and constant" at times.
Dr X specifically checked for the usual signs of meningism — neck rigidity, light aversion, nausea and headaches — but recorded in her notes that he looked well and had a "relaxed demeanour".
Their third session took place on January 6, 2012, after Mr Cuttance had again made a flurry of complaints to prison nurses in the lead-up.
He could not sleep, he had tingling lips, numbness, had been vomiting; he requested to go to hospital at one stage and said he had no faith in the OCF medical team.
Dr X believed the headaches might have been caused by the anti-anxiety medication and Mr Cuttance told her Panadol could take away the pain for several hours.
She performed a neurological assessment and a full physical examination and found no abnormalities, the court heard.
A plan was made for Mr Cuttance to see a physiotherapist.
But nine days later he was rushed to hospital and would not survive.
Under cross-examination,
Dr X accepted it was not her usual practice to look at the nursing notes before assessing a patient.
She said there was no indication that the doctor was aware of the sheer number of times the inmate had complained of headaches or the variety of symptoms.
That, she said, was a significant departure from a reasonable standard of care.
Another expert, Dr Teresa Turnbull, however, believed the oversight was not so serious.
It was a departure from best practice not to get a second opinion but she said Dr X worked hard to find a diagnosis.
Judge Kellar agreed.
"I have reached the conclusion that although best practice might have been for Dr [X] to have read the nursing notes on each occasion when she examined Boyd and to have referred him to a specialist following her 6 January 2012 examination, those were matters of judgement on which opinions may vary. And, that those matters were not a breach of a reasonable standard of care," he said.
"The cause of his illness was notoriously difficult to detect."
The judge dismissed Mrs Cuttance’s claims.
So would Mr Cuttance have been saved with earlier hospital treatment?
Dr Lewis believed that had anti-fungal medication been administered in December 2011, he "probably" would have lived.
If detected earlier, the lesion on Mr Cuttance’s brain might have been amenable to surgical removal, she said.
Ultimately, though, it was all speculation.
"We are guessing," Dr Lewis conceded.
While Mrs Cuttance has expressed her disappointment at her son’s treatment in court, she repeatedly refused to speak to the ODT about the case until it was finally resolved.
The appeal will be heard in the High Court in June.
A decade of despair
June 18, 2011: Boyd Cuttance sets fire to a car outside a Waihola bar.
Oct 22-30: Presents at Dunedin Hospital three times complaining of severe headaches.
Nov 28: Sentenced to two and a-half years’ imprisonment.
Nov 29: Mr Cuttance first sees Dr X; she believes he has tension headaches.
Dec 16: One of more than 20 interactions with nurses in which he complains of ongoing pain Dec 20: Second consult with Dr X, complains of ‘‘excruciating’’ pain but no signs of meningism.
Dec 22-30: Mr Cuttance sees nurses on a near-daily basis describing an array of symptoms.
Jan 6, 2012: Sees Dr X for the third time, experts agree she should have sought a second opinion.
Jan 15: Mother visits him in prison, finds him vomiting and unintelligible, taken to hospital.
Mar 28: Mr Cuttance dies in Dunedin Hospital; later found to have a rare fungal meningitis.
Jul 27, 2013: Coroner David Crerar releases provisional findings.
Nov 6, 2015: Mr Crerar makes his final findings public, says Mr Cuttance’s care was suboptimal.
Sept, 2021: Mrs Cuttance faces off against the attorney-general in the Dunedin District Court.
Dec 17, 2021: Judge Paul Kellar declines to make any declarations in favour of Mrs Cuttance.
Jun 2022: Appeal to be heard in the High Court at Dunedin.
