Wiltshire Coroner David Masters has asked hospital staff why they turned away depressed mum Katie Lee before she killed herself.
He also wants to know how the mother of three managed to stockpile enough prescription drugs to take a massive overdose.
Mr Masters heard that 39-year-old Mrs Lee, of Swan Cottages, Pewsey, had huge quantities of the drugs Quetiaprine and Citalpram, both supplied to her to manage her bipolar condition, in her bloodstream.
At the end of the inquest at Salisbury yesterday Mr Masters said he was satisfied that Mrs Lee took her own life on June 9 last year and intended to do so, but wanted answers about how her case was managed by the crisis home treatment team from Green Lane Hospital in Devizes.
In particular, he was concerned that there were enough drugs in the house for there to be 22,000 milligrams per litre of Quetiaprine found in her blood when the maximum therapeutic dose is 632 mg. The level of Citalpram was found to be 4,280 milligrams per litre, the maximum therapeutic dose being 160.
Mrs Lee’s husband Keith told the inquest that Mrs Lee was born and brought up in Oldham and the family came to Pewsey in 2006.
Mrs Lee had suffered from depression as long as he had known her and she had been under the care of a mental health team since her first child was born 12 years before.
Mr Lee had to cut short a business trip to Saudi Arabia on May 24 last year when he heard that his wife had taken an overdose of the prescription drug Diazepam.
He then instituted a carefully managed regime under which only the pills she needed for the day were made available to Mrs Lee.
The crisis home treatment team were alerted and they began making regular visits to the Lees’ home.
But on May 28 Mrs Lee harmed herself by cutting her arms with a knife.
Mr Lee arranged a trip to Center Parcs for himself and Mrs Lee along with her best friend, Kristin Warry, and her partner.
In the end, Mrs Lee declined to go on the trip and she stayed at home with her oldest child.
Mrs Lee went to bed on Thursday complaining of a migraine.
This was not unusual as during her periods of depression she would often spend days, and sometimes weeks, in bed.
Her eldest child checked on her through Friday, found her apparently asleep but did not want to wake her as she needed as much rest as possible during her periods of depression.
Her sleeping position had not changed by Saturday morning and she was cold to the touch. The child then contacted the next door neighbour who called for an ambulance.
Kristin Warry told the inquest that Mrs Lee had asked to be admitted to Green Lane Hospital, saying she needed a place where she could have peace and quiet to recover.
She was put off this by members of the crisis team who said she would recover more quickly at home.
Pathologist Dr Michelle Khan said Mrs Lee had died from an overdose and toxicologist Dr Immanuel Abu told the inquest Mrs Lee would have gone into coma and it was impossible to say exactly when she died.
Mr Masters expressed disappointment that an audit of Mrs Lee’s case by the mental health team was not available to him and said he needed answers regarding Mrs Lee’s request to go to Green Lane Hospital and the lessons learned from the case by the crisis home treatment team.
He declined to close the case and bring in a verdict until the additional information was before him.
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