A GP surgery in Bury has been given 21 days to show it has learned lessons over the way it prescribes drugs after a patient with mental health difficulties died from an overdose.
Mother-of-three Laura Hunter, 30, was found dead, fully clothed in the bath, at her home on Cornwall Drive in February this year.
Rochdale Coroner's Court heard she had a long history of mental health issues and using amphetamines.
Coroner Julie Robertston ruled her death resulted from misadventure after she took a rare form of amphetamine, more commonly found in central Europe.
The inquest heard Ms Hunter had made three previous overdose attempts, amid mental health difficulties dating back to a fairground accident, aged 14, which led to her leg almost being amputated.
One friend said she had been failed by professionals as she had never been given the chance to meet a psychiatrist.
The inquest heard from GP Shoba Chacko, from the Peel Surgery.
She said Ms Hunter registered as a patient in 2004 and had been seen for anxiety and depression.
She told the hearing Ms Hunter had been prescribed Propanolol and Fluoxetine and had first come to the practice for a sick note, for anxiety and depression, in May 2015.
Coroner Julie Robertson asked her: “Was she followed up by the surgery?”
The doctor replied: “Yes she was followed up by out-of-hours for panic attacks.”
She was then asked: “What were the surgery doing to see if she was managing her mental health?”
The doctor replied: “I wasn’t involved then.”
The coroner asked: “You have records?”
She replied: “Nothing to say we have done anything.”
The coroner also questioned the doctor on prescribing Propranolol in July 2019, which was in her system when she died.
The court heard the prescription was given before she attended, which was also queried by the coroner.
Toxicologist Julie Evans said Ms Hunter had Propanolol and amphetamines in her system when she died, as well as fluoroamphetamine, a rare drug.
She said Ms Hunter would not have known the difference between this and the more commonly found amphetamine.
Coroner Mrs Robertson said she was giving the surgery 21 days to detail what it may do differently in future.
Recording her conclusion, the coroner added: "I thought about the conclusion of suicide, I am not satisfied that Laura took her own life and she intended to take her own life. It is possible but a possibility isn’t enough. This is one of misadventure.”
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