“The possible toxicity from the Co-codamol tablets was not a considered by the ambulance…”
Dated 9 Feb 2024, from the coroner for West Sussex, Brighton and Hove. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
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All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated9 Feb 2024
- Deadline5 Apr 2024
- Published on judiciary.uk15 Apr 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Sussex Integrated Care Board | Response publishedPublished on judiciary.uk in April 2024. |
The coroner’s concerns
The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs Young following a 999 call. The Ambulance Service was not aware that Mrs Young had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records. There was a short period of time in which the Naloxdone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxodone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily Regulation 28 – After Inquest Document Template Updated 30/07/2021 available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2024-0182
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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