Gary Evans

An Upper Hutt preschooler's death from swallowing his mother's methadone tablets could have been prevented if they were in a childproof container, a coroner says.

Wellington coroner Garry Evans has called for the Government to adopt legislation which would develop standards for child resistant packaging -- something Parliament dismissed in 2007.

Four-year-old Callum Munro was found on the afternoon of April 26, 2009 "cold and stiff to touch and purple in colour" on the couch where he fell asleep the night before, an inquest was told.

When an ambulance arrived, he was confirmed dead.

On the night before he died he was watching a movie with his mother Janelle Treanor and his two sisters, when he vomited twice -- the only indication he was sick.

In findings released today, Mr Evans said Ms Treanor had been prescribed methadone by her GP for relief of facial pain, taking 5mg a day, which had been dispensed in the manufacturer's glass jar, which was not fitted with a childproof lid.

The medicine was kept in a kitchen cupboard with a childproof safety latch, though Ms Treanor told the inquest her daughters were capable of getting into the cupboard.

While Ms Treanor never saw Callum take the methadone, in his post-mortem report forensic pathologist John Rutherford concluded Callum died from methadone toxicity.

As a response to Callum's death, Mr Evans wrote to Health Minister Tony Ryall requesting the Government gave favourable consideration to adopting the Draft Managing Director's Order -- a joint venture with Australia which included the development of standards for child resistant packaging.

In 2003 the Australian and New Zealand governments signed a treaty to establish this agency, but the New Zealand Government announced in 2007 it would not be proceeding with legislation that would have allowed its establishment.

New Zealand medicine regulations state there must be strip or blistering packaging "reasonably resistant" to attempts by young children to gain access to some medicine.

The list of medicines included aspirin, antidepressants and paracetamol -- but was "out of date and too limited" according a report compiled by National Poisons Centre director Wayne Temple at the request of the coroner.

In addition, Pharmac funded child safety caps for oral liquid preparations, and a code of ethics for pharmacists encouraged them to place child-resistant packaging on a wider range of medicines involved in child poisoning.

Mr Evans concluded that "had the container holding Ms Treanor's methadone been fitted with a child resistant closure, or in the absence of such closure, been placed in a locked cupboard, Callum's death would have been prevented."

Mr Evans sent his request to Mr Ryall, with support from Dr Temple's report.

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