A family has paid tribute to their "ambitious, fearless and inspirational" 21-year-old son at an inquest into his death. 

Leon Norte-Clarke, from Ipswich, died in the early hours of June 29, 2022, as a result of a medication overdose. 

The inquest heard he had been given six weeks worth of propranolol tablets, which is the standard amount, after visiting his GP - however the surgery had flagged the number of tablets should be reduced due to Leon's medical history.

The court heard the 21-year-old had gone into his parent's room at around 4am on June 29 2022, 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.

During Thursday's hearing, his parents said: "He was such an inspiration, even from a young age.

"He loved being outside and the freedom and beauty of nature.

"He loved swimming and playing water polo, which he did for Ipswich and Chelmsford, and got a trial for Team GB.

"Leon was intelligent and insightful, capable and ambitious."

Suffolk Coroner's Court heard evidence from his parents that he had been under a mental health team since he was 14, and had been getting regular medication help, which was kept in their bedroom and given to Leon daily when he needed it.

His dad said: "I didn't know how many tablets he had been prescribed, if I had, I would have taken the vast majority off him and given him an appropriate amount every day."

Dr Jonathan Knight, partner at Two Rivers Medical Centre in Ipswich, where Leon had been a patient, gave evidence. 

Dr Knight was not involved directly with Leon's care, with his involvement coming from a supervisory level.

He said: "My understanding is that Leon had been on a Serious Mental Illness (SMI) list at a previous hospital, but when he moved to us, it was deemed the bipolar he had previously had been resolved.

"There was a debrief carried out between the prescribing GP, Dr Emilija Dakneviciute and myself.

"We had noted together that there was a history of overdose and self-harm and because of that discussion, the view was to reduce the number of tablets to mitigate the risk.

"After the debrief, we contacted the prescribing team within the practice to see if they could recall the prescription to reduce the number of tablets, but they were unable to do so.

"If a prescription has not yet been downloaded by the pharmacy, it can be recalled. We made efforts to contact the dispensing pharmacy directly."

Dr Emilija Dakneviciute, who was a trainee doctor at the time of Leon's death at Two Rivers Medical Centre was the prescribing doctor who saw Leon for follow-up checks before his death.

In court, she said: "I was in my third year training as a GP, I saw him for the first time on May 3, 2022, when he was complaining of nasal issues and headaches.

"We rearranged a follow-up meeting, for May 16, where I looked at his nasal issues, and he also complained of having chest issues.

"He still had headaches so I prescribed him six weeks worth of propranolol, which is a common prescription for headaches.

"That is when Dr Knight and I had our debrief and he suggested lowering the number of tablets.

"I sent an urgent message to our in-house team, but that was unsuccessful, and the task was closed on May 19.

"I was not aware his parents were managing his prescription.

"When I saw him on June 13, he was very much improved and it was a positive picture, and he said the propranolol was helping.

"I prescribed him another six weeks' worth of tablets at this point. It wasn't in the forefront of my mind to reduce it, I think because it was such a positive image, it negated the risk, but I agree, it should have been a lesser prescription."

The inquest continues.