A WOMAN who died after accidentally over-dosing on methadone had obtained prescription pills from more than one outpatient clinic, an inquest heard.
Carla Berger, of Mascalls Way, Chelmsford, died on March 4 after she had spent the night watching TV at her home.
A post-mortem examination found traces of methadone in her blood at a concentration higher than expected. Choking was also given as cause of death.
Miss Berger, 25, had a history of serious mental health and substance misuse issues dating back ten years. She overdosed seven times in 2006 and 2007.
She was prescribed fluoxetine during a number of stays at the Linden Outpatient Centre and took diazepam. She developed epilepsy and became antipsychotic.
Miss Berger had been getting prescriptions from two outpatients surgeries and her GP – although they did not know she was being given pills by the other surgeries due to there being no shared database.
Coroner Caroline Beasley-Murray said she was “taken aback” to find the young woman’s death had failed to result in an action plan from North Essex NHS Trust representatives and said it didn’t conform with Care Programme Approach policy – which helps people with severe mental problems.
Nigel Butcher, team leader of the Chelmsford Adult Mental Health Team, said an action plan would be produced this week.
Lorraine Berger, Carla’s mother, said the family had suffered anguish and trauma over the past ten years.
She said: “Carla wasn’t given a chance and is the victim of neglect. There was a lack of communication, showing clear failings in the system.”
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