In the Suffolk Coroner’s Court

Before HM Assistant Coroner Catherine Wood

On 7-8 March 2024; 24-25 June 2024

The inquest into the death of Leon Nathaniel Norte-Clarke concluded today (25 June 2024) before HM Assistant Coroner Catherine Wood.

Leon sadly died, aged 21, on 29 June 2022, following taking an overdose of Propranolol tablets.

Leon was much loved by his family. The Court heard how Leon loved being outside and how he loved the freedom and beauty of nature. Leon always found time to help others and he fundraised a lot of money through completing obstacle challenges and taking on the Great North Run.

Today, following submissions on behalf of the family that the test for a conclusion of suicide was not met and inviting a narrative conclusion, the Coroner returned a narrative conclusion that Leon died as a consequence of impulsive Propranolol overdose, despite attempting to seek help after ingestion. In Box 3 of the Record of Inquest, the coroner recorded a number of other findings including:

  • ‘…whilst it is likely he suffered from Emotionally Unstable Personality Disorder he did not have a formal diagnosis in part due to not having had a medical review due to staffing issues’

  • ‘[H]e was also noted to be at risk of stockpiling medication’

  • ‘On 5 May 2022 [Leon] attended hospital having inhaled some lighter fluid with mixed intention but did not require inpatient admission and was discharged back to the care of his community team with a letter sent to his GP surgery outlining his risks’

  • ‘On 16 May 2022 he was seen … at the GP surgery and prescribed a six-week supply of Propranolol for his headaches. Having seen a trainee supervision took place and it was considered that a shorter supply or lower number of tablets should have been issued. He was seen again on 13 June 2022 and he felt that Propranolol had helped both his headaches and his anxiety and a further six week supply was issued’

Leon had suffered with his mental health for some time and had a history of self-harm, including previous overdose attempts. He was previously admitted for inpatient treatment following a decline in his mental health. Leon had a number of possible diagnoses, including: Rapid Cycling Bipolar Disorder, traits of Emotionally Unstable Personality Disorder (EUPD), depressive episodes, traits of Autism Spectrum Disorder, hallucinations and delusions, pseudo seizures and previous auditory comment resulting in self-harm.

At the time of his death, Leon was under the care of the Crisis Resolution and Home Treatment Team under Norfolk and Suffolk NHS Foundation Trust (NSFT). A number of concerns were raised in their Patient Safety Investigation Report, including:

  • Lack of clarity around Leon’s diagnosis and therefore a lack of understanding around the formulation of best to provide support.

  • Leon’s requests for a medic appointment to clarify his diagnosis were not actioned in a timely way.

  • Failings in policy around record keeping, with the investigation finding a number of system factors that influenced this.

  • There was no team medic available at the time and systemic factors included large caseloads, high acuity patients and care co-ordinators providing support to colleagues with their cases. Evidence was given at the inquest that the team were frustrated as it was recognised that there was a need for a lead consultant.

The Coroner made findings that there was no consultant psychiatrist in the team and there was no formal diagnosis of Leon having EUPD, however, found that whilst this may have helped Leon, she could not say that it caused or more than minimally contributed to his death.

In May 2022, Leon had previously disclosed to medical professionals that he was stockpiling medication. The same month, Leon had been prescribed Propranolol to assist with headaches by a GP in their third year of training. Whilst this information was provided to the GP, it in was in the body of a lengthy letter rather than the risk of stockpiling medication being clearly highlighted. Evidence was given that NSFT accept that “a far more robust system and automatic system” is required to flag concerns.

The trainee GP was aware Leon had a history of anxiety and possible Bipolar and EUPD traits and was also aware that on 5th May Leon had attended A&E following ingesting lighter fluid and was seen by the psychiatric liaison team but did not consider the risks of stockpiling. During a supervisory session with a senior GP, it was suggested that the number of Propranolol tablets prescribed should be reduced. Unfortunately, attempts made with the pharmacists to reduce the prescription were unsuccessful. The Propranolol prescription was repeated on 13th June. The Coroner found that the trainee GP shouldn’t have prescribed the 84 tablets on both occasions and should have prescribed a lesser number of tablets, describing this as a “failure to prescribe a lower number of tablets”.

In the early hours of 29 June 2022, Leon told his parents that he had taken an overdose of medication. His family called 999 at 04:08, however, the first ambulance crew was not dispatched until 04:43. Leon was not taken to hospital until 06:30 and was sadly pronounced dead at hospital. A witness from Ipswich Hospital Emergency Department told the Court that it was possible that earlier treatment could have made a difference, but was not able to say whether it was probable that earlier treatment would have made a difference.

The Coroner found that there was a delay with the ambulance being allocated at that rather than arriving within the Category 2 target time of 18 minutes, it was more like 45 minutes from the beginning of the 999 call to the ambulance arrival.

The inquest heard evidence that the East of England Ambulance Trust (EEAST) were operating under ‘Surge Black’ that evening due to the demand on the services. EEAST accepted in their Patient Safety Incident Review that the ambulance provision was below the target required. Evidence was given that although the codes have changed, EEAST were last operating at this equivalent level just a few days ago and that they are not currently meeting their targets for responding to Category 2 graded 999 calls. The Coroner noted that there are national issues with the ambulance service.

The Interested Persons for the inquest were:

  1. The Family

  2. Norfolk and Suffolk NHS Foundation Trust

  3. Two separate GPs at Two Rivers Medical Practice

  4. East of England Ambulance Trust

  5. Boots Pharmacy

Xavier Norte and Deborah Clarke, Leon’s parents, said:

“We just want to thank all the Frontline staff who supported Leon, especially his care coordinator who went above and beyond for Leon, despite not having access to appropriate resources or a medic.

“We have been emotionally exhausted by the Inquest process but hope that some good can come from it through changes that will reduce the risk of this happening in the future.

“We miss Leon dearly but we know he’d be proud of the way we have fought for him. That brings us solace.”

Alice Wood of Farleys Solicitors and Anna Moradi of 12 King’s Bench Walk said:

“Every child and young person should have the access to the care they require to keep them safe. The attitudes of many professionals were dismissive of Leon’s requests for medication reviews and his disclosures of stockpiling.

One of the family’s main concerns is that the tragic events that led to Leon’s death are not repeated and yet at the inquest some of the witnesses could not answer basic questions around current response levels and the measures now in place to prevent this from happening.

We support the family and the wider calls for a national inquiry into Norfolk and Suffolk NHS Foundation Trust.”

Leon’s family are represented by Alice Wood, Solicitor and Joseph Bridge, Trainee Solicitor of Farleys, alongside Anna Moradi of 12 King’s Bench Walk.