STAFF at a sheltered housing facility took almost four hours to check up on a resident after being warned he had taken an overdose, an inquest has heard.
Robert Mark Mason, 33, was living at Canterbury House in Thetford when he died on March 14, 2009.
An inquest in Bury St Edmunds on Wednesday heard how paramedics were called to a suspected overdose at Canterbury House at around 12.30pm on March 11.
But Hassan Sesay, a worker at the housing accommodation, said he had been warned about Mr Mason having taken the potentially lethal combination of amitriptyline and co-codamol at 9am.
When Mr Sesay and colleague Melanie Jeanes had checked on Mr Mason at 11.30am, they said they thought he was asleep and that he appeared to make a gesture with his arm to suggest he was okay.
However, no attempt was made to rouse him and it was only when another resident warned staff again that further checks were made.
At the conclusion of the five hour hearing, coroner Dr Peter Dean said Springboard East Anglia, who run the building, would need to address their first aid training.
“We are not here to point blame but clearly if there are lessons to be learned then they should be learned,” he said.
The inquest also heard how Mr Mason had been unable to speak to a psychiatrist about his ongoing depression and anger management issues despite being referred twice.
Dr John Bryson, Mr Mason’s GP, said his patient had told him his life was ‘worthless’ and that he would be ‘better off dead’.
However, when he referred him to psychiatrist, Simon Gatehouse, the appointment was not kept as Mr Gatehouse had relocated to King’s Lynn and the appointment was never rescheduled.
Dr Dean said it was impossible to tell if the failure to react earlier to Mr Mason’s overdose would have prevented his eventual death.
The verdict was of death from complications following a mixed drug overdose.