Coroner's Court of Western Australia

Inquest into the Death of Amy Rebecca DEANE-JOHNS

Inquest into the Death of Amy Rebecca DEANE-JOHNS

Delivered on : 13 August 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Amy Rebecca Deane-Johns (Ms Deane-Johns) was 48 years of age when she died on or about 29 March 2022 from combined drug toxicity (predominantly methadone).  At the time of her death, Ms Deane-Johns was subject to a community treatment order (CTO) made under the Mental Health Act 2014 (WA).  Accordingly, Ms Deane-Johns was an “involuntary patient” and thereby a “person held in care”, and her death was a “reportable death”.

Ms Deane-Johns’ interaction with mental health services began in 2013 when she was 39 years of age.  Between 2016 and her death, she had 18 admissions to inpatient mental health units, as either a voluntary or an involuntary patient.  During her inpatient admissions Ms Deane-Johns disclosed her history polysubstance use including methamphetamine (which she had reportedly started using at the age of 14 years), benzodiazepines, and alcohol.  She also occasionally used heroin, and had experienced a heroin overdose in 2016.

Ms Deane-Johns was managed by the Duke Community Treatment Team (the Team) from January 2018 until 18 February 2022.  It had been determined that Ms Deane-Johns required a greater level of service, and she was eventually transferred to the Intensive Community Outreach Team (ICOT), having being referred to the service in about July 2021.

Ms Deane-Johns was reviewed by her treating psychiatrist and her case manager during a home visit on 14 March 2022.  During this review, Ms Deane-Johns appeared to be distracted by unseen stimuli, and it was noted that her compliance with oral medication had been intermittent.  In view of Ms Deane-Johns’ presentation, and given her lack of insight into her need for treatment, and her poor compliance with medication, it was decided to place her on a CTO, and she was prescribed a depot injection of antipsychotic medication.

On 29 March 2022, Ms Deane-Johns spent the day with her nephew, and when he dopped her home at about 5.30 pm, he told her he would visit her the following day.  When the nephew arrived at Ms Deane-Johns’ home at about 11.20 am on 30 March 2022, there was no response to knocks on the front door.  The nephew walked through the unlocked front door and found Ms Deane-Johns sitting, unresponsive, on the floor, apparently deceased.  The nephew called emergency services, and ambulance officers arrived and confirmed that Ms Deane-Johns had died some time earlier.

Police attended and found one empty bottle of methadone on the kitchen bench, and two full bottles of methadone in Ms Deane-Johns’ handbag.  Police enquiries determined that the bottles of methadone had been dispensed about 12-months earlier to one of the nephew’s relatives.  The nephew told police that the bottles of methadone had been in the glovebox of his car, and that Ms Deane-Johns must have taken the bottles from the glovebox of his car without his knowledge.

The coroner concluded that Ms Deane-Johns’ management whilst she was the subject of a CTO was reasonable, and the supervision, treatment and care she received during that time was of a good standard.

The coroner was also satisfied that the decision to place Ms Deane-Johns on a CTO was justified on the basis that it was the least restrictive way to ensure that she was provided with appropriate treatment for her mental illness.

Catch Words : Community treatment order : Polysubstance use : Methadone toxicity : Natural Causes


Last updated: 11-Sep-2024

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