The parents of an "intelligent and ambitious" 21-year-old have paid tribute to their son following the conclusion of his four-day inquest.

Xavier Norte and Deborah Clarke, the parents of Leon Norte-Clarke, have paid tribute to their son for the first time since Suffolk Coroners' Court concluded he did not intentionally take his own life.

Mr Norte-Clarke died on June 29, 2022 after he overdosed on propranolol tablets, which were prescribed medication.

HM assistant coroner Catherine Woods said in her reading that Mr Norte-Clarke "did not want to die", recording a narrative conclusion.

She also noted that there are national issues with the ambulance service, with the East of England Ambulance Service arriving 45 minutes after the initial call to 999, despite a target time of 18 minutes.

Mr Norte and Miss Clarke said in a statement: "He was such an inspiration, even from a young age.

"He was intelligent and insightful, capable and ambitious. He loved being outside and the freedom and beauty of nature.

"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."

Following Mr Norte-Clarke's death, measures and steps have been put in place or are being developed by local authorities.

Norfolk and Suffolk NHS Foundation Trust is to develop an alert system which will work with GPs to flag any urgent alerts with regards to a person's medical history or potential medication risks.

This is after Mr Norte-Clarke was prescribed six weeks worth of tablets twice, with concerns of stockpiling - but the number of tablets wasn't reduced, and the stockpiling alert wasn't flagged to the GP.

Alice Wood, of Farleys Solicitors, and Anna Morardi of 12 King's Bench Walk, who represented the family at the inquest, 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 what measures are 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.”