The death of a 21-year-old Ipswich man who was "ambitious, fearless and inspirational" was not intentional, an inquest has concluded.

Suffolk Coroners' Court found that Leon Norte-Clarke, who died nearly two years ago following a prescribed medication overdose, did not intend to end his life.

Mr Norte-Clarke, who was described by his parents as "intelligent and insightful, capable and ambitious", died in the early hours of June 29, 2022.

Throughout the inquest, several witnesses who were involved in Mr Norte-Clarke's life in the months leading up to his death, provided statements and evidence.

Assistant coroner Catherine Wood concluded in her summary: "Leon died as a consequence of an overdose that I do not believe to be intentional.

"I am satisfied Leon took his life, but I am not satisfied with his intention. This was likely an impulsive decision but the key is going to his parents' room to tell them that he wanted and needed help.

"He didn't want to die."

The four day inquest concluded todayThe four day inquest concluded today (Image: Newsquest)

Mr Norte-Clarke had asked his parents to call 999 at 4.08am that morning, which his parents did immediately.

Due to his condition at the time of the call, the coroner was satisfied with the category of urgency the call was placed in.

She continued: "The ambulance didn't arrive within the target time for a category two call of 18 minutes. It was more like 45 minutes, so that is quite off the target time.

"I cannot say, however, if getting an ambulance to Leon sooner would have helped."

Mr Norte-Clarke had been under a mental health team since he was 14 and had been getting regular medication help.

When the inquest began, the court heard how he was prescribed six weeks' worth of propranolol tablets, the standard amount.

This was a concern raised, however, by the surgery which attempted to lower the number of tablets provided.

The coroner added that the number of prescribed tablets should have been reduced.

A system is currently being developed between Norfolk and Suffolk NHS Foundation Trust and GP surgeries so that anything that is seen as needing urgent attention, such as a patient's medical history or a potential risk, is being flagged up as a result of Mr Norte-Clarke's death.