It may never be known who injected a fatal dose of home-bake morphine into the arm of a 21-year-old addict and alcoholic who later died in hospital.
Israel Evart Hart died in Auckland City Hospital a day after taking a "potent" combination of drugs and alcohol at his father's apartment in November 2013.
In a finding released yesterday Coroner Debra Bell ruled there were only three people who could have injected Hart - he either self administered, or it was injected by his father Richard Hart, or David Park who made the drug.
She found it was "more likely than not" that Hart didn't inject himself, but didn't go any further, saying it was not for her to determine criminal liability, nor to speculate.
Police investigated but had insufficient evidence so it's unlikely anyone will ever be charged in relation to Hart's death.
The inquest findings detail the tragic downfall of a young man who start smoking cannabis every day from around the age of 14 with the knowledge of his mother.
The mother said she "permitted her children to consume cannabis at home, reasoning it was better for her to know what drugs they were taking rather than them consuming drugs elsewhere".
At 16, Hart, who was raised by his mother, wanted to get to know his father better.
Around the same time he started drinking and Hart Snr described his son as being "angry and using cannabis" around the time he came back into his life.
Over the following years he became so dependant on drugs and alcohol that he had three accidental overdoes. At various times he was smoking up to "four cones" a day, taking up to seven party pills combined with ecstasy and LSD, and drinking seven litres of cask wine.
His parents tried to get him treatment through numerous agencies, to no avail, and he eventually ended up unconscious on his father's bed after being injected for the final time.
The findings refer to numerous attempts being made by agencies and Hart himself to get clean. At 19 he self-referred due to his concern about his risk to others while drinking.
"This was as a result of an incident when he stabbed his father in the arm with a kitchen knife when they were both intoxicated."
He was suicidal at times and described his use as being "four cones a day" to the Child and Adolescent Mental Health Service (CADS).
Hart indicated to those trying to help that there was a time in 2009 where he was smoking cannabis every hour and also using methamphetamine on a daily basis. The previous year he was taking up to seven party pills a night in combination with ecstasy and LSD.
In June 2012 he had further contact with CADS for major depression, chronic anxiety and cannabis use. Hart, who was smoking up to three joints a day, roughly four times a week, was started on medication, including antidepressants.
He stopped treatment saying talking about his problems "made him feel weak" but self-referred to the service again the following year after attempts to stop using alcohol and opiates left him with withdrawal symptoms.
"He had previously reported past alcohol withdrawal seizures and was beginning to experience alcohol withdrawal symptoms of tremor and sweating at the time of referring himself."
During subsequent appointments he described escalating alcohol use and patterns of binge drinking for several weeks at a time before abstaining again. He would black out on a daily basis while drinking and had suffered three unintentional overdoses and a seizure.
By this stage he was using 60 milligrams of morphine home-bake intranasally while drinking.
Friends gave evidence that Hart could drink up to six litres of a cask of wine in a day and would "romanticise heroin when he spoke of it". They labelled him an alcoholic who was "jittery and would talk to himself".
A boyfriend described how Hart confided he was getting drugs off a friend of his father's called Dave. Dave was later identified in the findings as David Park.
"Dave had the best heroin as he was mixing morphine with paint stripper".
During the last six months of his life Hart lived a transient lifestyle, either on the street or at his father's home.
On November 13 Hart's father said he was in his room drinking when his son came into the room and lay down on his bed. His son's eyes were open but it wasn't until he returned to the room after getting another bottle of alcohol that he realised something was wrong.
"He smacked him on the face but did not receive a response."
Hart Snr then called and ambulance, saying his son had "taken heroin or something" and started CPR.
He was taken to hospital and died the next day after life support was turned off.
An autopsy revealed Hart had alcohol and morphine in his system. A forensic pathologist said the level of morphine was low and not at a level that would normally result in death.
However when mixing it with alcohol "you really are mixing petrol in on tip of the fire, it becomes a very potent combination".
Bell described Hart's death as a tragic accident. It wasn't clear however who had administered the drug.
"In the circumstances, I do not accept Mr Richard Hart is a credible witness on matters that are relevant to my inquiry. Mr Park's recall was scant and I sensed for reasons only know to Mr Park he was not willing to provide too much information."
Regardless she didn't believe there was any intent by anyone to cause him harm.
She finished her decision saying it was apt to quote Park:
"Some people like to escape and get high; some people find it very hard to deal with this life and the only way to deal with it is by getting loaded. People don't even mean to hurt anyone; the intent is not for people to die or hurt themselves. It is a little bit of escapism, you know, a little bit of respite from the nightmare. It should never have happened, he was a bloody good kid and it's just a disgrace."