Amy Rebecca Deane-Johns, aged 48, died from combined drug toxicity predominantly involving methadone that she had taken without knowledge or authorization. She had a long history of mental illness with 18 inpatient admissions between 2016 and 2022, chronic polysubstance use including methamphetamine and alcohol, and was under a Community Treatment Order (CTO) at the time of death. The Intensive Community Outreach Team (ICOT) provided regular reviews and case management over a six-week period. An expert psychiatrist found the treatment "very solid" with nothing that should have been done differently. The methadone bottles were not prescribed to her but had been dispensed 12 months earlier to a relative and were found in that relative's car from which she took them. The coroner found the supervision, treatment and care provided was reasonable and of good standard, though the patient's ongoing polysubstance use and refusal of rehabilitation services presented significant management challenges.
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