A psychiatric nurse said there may have been an "oversight” in highlighting risks after a 21-year-old passed away following an overdose, an inquest has heard.

The inquest into the death of Leon Norte-Clarke from Ipswich continued in Suffolk Coroner's Court on Friday, with witness statements saying the young man had been feeling suicidal for four years.

A post-mortem report found Leon suffered a cardiac arrest following a medication overdose, passing away in the early hours of June 29, 2022.

The inquest heard how Leon had been diagnosed with rapid cycling bipolar disorder as a teenager, and had been referred for an autism assessment after speaking to a spectrum development specialist.

He had been previously hospitalised after concerns for his safety.

Victoria Warren, psychiatric nurse in the liaison department, gave evidence regarding Leon’s visit to the Emergency Department. 

HM Assistant Coroner Catherine Wood questioned why risks were not highlighted as the court had heard Leon had spoken of stockpiling medication and suicidal feelings.

Ms Warren said this may have been “an oversight”.

She also said that Leon had “hope for the future” and was focused on recovery, and so the team was not convinced that he would act upon his feelings.

In another statement, Joanne Smith, Leon’s allocated care co-ordinator from November 2021, was asked how Leon presented on June 22, a week before he died.

She told the court there was a lack of resources in medical intervention and psychologists at the time of Leon's death.

Ms Smith described how he was a “little bit slow” but that he was feeling “positive” and “wanted to get better”.

The coroner asked if there was anything she could have done in terms of signposting at the time, Ms Smith said: “I think we did what we could with the resources available at the time.”

She also described him as an “intelligent, charismatic young man”.

The court heard earlier this week how he had been given six weeks’ worth of propranolol tablets, which is the standard amount, after visiting his GP, and the surgery had flagged the number of tablets should be reduced due to Leon's medical history.

The 21-year-old had gone into his parent's room at around 4am on June 29, telling his parents to call 999, which they did at 4.08am.

The first ambulance crew was not dispatched until 4.43am however, and Leon was not taken to hospital until 6.30am. He was pronounced dead upon arrival at Ipswich Hospital.

The inquest will continue in June.

If you need urgent mental health support call NHS 111 and select option 2 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week.