A 999 call stating that a man had taken 100 Paracetamol tablets and was “dying on the floor” was not given top priority by the ambulance service.

The call was later upgraded but then it took two hours for an ambulance to arrive at John Owen’s home, and paramedics had to wait for police officers to gain entry to the premises.

They found 60-year-old Mr Owen hanging in his bathroom and a post-mortem examination revealed that he had taken a fatal number of tablets.

At the close of an inquest in Ruthin Elizabeth Dudley-Jones, assistant coroner for North Wales East and Central, said she had initially been very concerned about the way the call had been coded but those concerns had been allayed after hearing evidence from Gill Pleming, utilization manager for the Welsh Ambulance Services Trust.

In a statement read at the hearing Mr Owen’s daughter Jenny Owen said her father, a tugboat skipper, had had a drink problem throughout his life and could be violent when in drink.

When his wife told him to leave in late 2017 he became very depressed and, according to his daughter, he “went on a downward spiral” when his wife did not send him a card on his 60th birthday, causing him to drink heavily.

By February, 2018, he spoke of self-harming and was admitted to the Ablett Unit at Glan Clwyd Hospital, but discharged to the care of the community mental health team after two days.

Consultant psychiatrist Dr Colin White told the inquest he believed that the decision to discharge him was correct as he was talking of going back to work in March.

Asked by the coroner if, in retrospect, Mr Owen should not have been discharged so soon, Dr White replied: “It was appropriate. He wanted to go home.”

Betsi Cadwaladr University Health Board also carried out a root cause analysis which upheld all the actions taken in Mr Owen’s care and treatment.

Within a week of his discharge he was visited by a member of the mental health team three times, but on February 26 a Facebook entry was seen indicating that Mr Owen, who lived at the Old Palace, St Asaph, intended to kill himself and saying goodbye to his family and friends.

Jenny Owen told the inquest she called the police but hung up after 20 minutes. Her brother Christopher, who lives in Denmark, then received a text message saying he had taken an overdose and that paramedics were taking a long time to reach him.

At 22.59 Jenny called 999 for an ambulance and the call was graded as Amber 2, which meant the situation was serious but not life-threatening., partly because Mr Owen was known to be breathing and clearly communicating.

An ambulance service clinician tried three times to call Mr Owen and at 23.33 the call was upgraded to Amber 1, still below the Red Code which meant an immediate threat to life.

Mrs Pleming said it was an extremely busy night, with 12 Amber 1 and 15 Amber 2 calls waiting at that time, which was why paramedics did not arrive at the Old Palace until 01.23. Having understood by Jenny that her father could become violent they then had to wait for the police to arrive.

Following Mr Owen’s death the calls and responses were independently audited and it was found that the procedures had been correctly followed.

“There was not an opportunity missed to allocate an ambulance,” said Mrs Pleming.

Since the beginning of this year, she added, the script used by call-takers had been changed, and they now gave callers an idea of long they might have to wait for an ambulance. The coroner said she was reassured by that.

Recording a narrative conclusion, Mrs Dudley-Jones said that two notes found in the flat showed that Mr Owen intended to kill himself though at one stage his call referring to “paramedics taking their time” showed he may have been expecting to be found.