Medical notes suggest Steven Freeman was admitted to the jail's methadone program without a urine test that might have revealed if he was telling the truth about his drug use, an inquest has heard.
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Lawyers at the Indigenous man's coronial inquest on Tuesday agitated the question of his "opiate naivety". The question has emerged as a critical one, as contrasting evidence of Mr Freeman's drug use has been put before Coroner Robert Cook.
Mr Freeman, 25, was discovered dead in his cell in the south wing at the Alexander Maconochie Centre about 11am on May 27, 2016.
Medical records show he had been admitted to the methadone program two days earlier, on May 25, and had received a 30mg dose of methadone from the health clinic that day and the day after.
The inquest heard the level of methadone in his blood was low, and fell within the range of therapeutic and toxic. But methadone tolerance is complex, in that different levels can affect people differently. What is toxic to one, may have little impact on another.
Medical notes say Mr Freeman had complained to a doctor of withdrawal symptoms. The inquest has also heard he told another inmate he'd had a few "drinks" of methadone from other prisoners.
That was described as someone regurgitating an oral dose of methadone, and mixing it with liquid which is then consumed.
A forensic physician said on Tuesday she could not "reconcile" the "very, very low" level of methadone found in Mr Freeman's blood with the two doses of methadone and circumstances of his death.
"I can't attribute that to an experienced opiates user. In my view, that would show a naive user," Dr Angela Sungaila told the court.
The doctor, who had experience prescribing methadone, said monitoring a person that had just started on methadone is "critical", in case signs of intoxication appear.
"That is that, the [first] dose may be too high or dangerous.
"And if those observations are made then the dose can be reduced or not given on that particular day, but it does require observations, by preferably a medial person, who is trained in picking up those signs."
Signs include drowsiness, slurred speech or an alteration in mood.
The inquest had earlier heard evidence Mr Freeman was "smashed" and "stoned" in the afternoon and evening before his death, although there are also suggestions this may not have been the case.
Dr Sungaila cautioned that even if outwardly Mr Freeman appeared unaffected by methadone, some symptoms were not as observable.
She said urine testing was useful in "corroborating" patient history.
There was also great utility in continuing drug urinalysis after starting methadone, whether in corrections or the community. Risks are highest in the first few weeks of methadone treatment, she said.
The medical notes make no mention of urine tests, the inquest heard.
Under questioning by Philip Walker SC, who is representing the methadone prescribing doctor, Dr Sungaila said her assessment of Mr Freeman as opiate naive might change, if he was regularly accessing methadone outside a prescription. But several occasions of that would not have meant he developed tolerance, she said.
She also agreed, under questioning by Ken Archer, who is representing the ACT government, most people who died in connection with methadone had another drug in their system.
It was also true that in cases where only methadone was present, a sizeable percentage of deaths involved diverted methadone, that is, methadone not prescribed by a doctor, she said.
Mr Freeman's former cellmate Jermaine Goolagong also gave evidence at the inquest hearing on Tuesday, telling the court Mr Freeman's last words were "I love ya, cuz" as Mr Goolagong, woken by Mr Freeman's snoring, had roused his friend from his sleep.
He said Mr Freeman had said he wanted to get on methadone to "get high". But though he was warned against it, Mr Gooalagong said the drug was "one of the easiest things you can get on in there."
He said the cordial bottles found in their cell held water they used to clean the cell. He admitted he owned the "sleepers", contraband pills found in their cell, and said Mr Freeman never took them. He said he never saw Mr Freeman, who was "just straighty-180", get high.
Professor Johan Duflou, a forensic pathologist who performed the autopsy on Mr Freeman, gave evidence the cause of Mr Freeman's death was aspiration pneumonia due to methadone toxicity. He described how aspiration pneumonia caused lungs to become inflamed after a person had inhaled fluid, often stomach contents, but also vomit. Methadone could suppress a person's cough response.
A hair sample taken from Mr Freeman's body after his death revealed two substances - methadone and Tramadol, another opioid. Professor Duflou said the latter drug was not in Mr Freeman's blood sample.
The hearing continues before Coroner Robert Cook.
