Suffolk Coroner’s Court
Before HM Assistant Coroner Catherine Wood
Opens Thursday 7 March 2024
Listed for two days

The inquest into the death of Leon Norte-Clarke is listed to take place on 7-8 March 2024 before HM Assistant Coroner Catherine Wood.

Leon sadly died, aged 21, on 29 June 2022. He was much loved by his family. Leon had a significant history of self-harm and hospital admissions and had been diagnosed with a number of mental health needs.

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.

The East of England Ambulance Trust have accepted in their Patient Safety Incident Review that the ambulance provision in the local area at the time was below the target required. Sadly, Leon’s death was pronounced after arriving at hospital.

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) and a number of concerns were raised in the NSFT Patient Safety Investigation Report.

There are also concerns around the GP and pharmacy staff following Leon disclosing that he was stockpiling medication in May 2022.

The inquest is set to cover the events leading to Leon’s death, to include his treatment at his GP surgery and his management by those at NSFT, focusing predominantly on the last 6 months of his life.

The Interested Persons for the inquest are:

  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

The family will not be making any comments until the conclusion of the inquest proceedings.

Leon’s family are represented by Alice Wood, Solicitor at Farleys, alongside Annahita Moradi of 12 King’s Bench Walk.

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