PFD report

Susan Mary Young · Prevention of Future Deaths report

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Issued 9 Feb 2024•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure by ambulance crews to consider possible medication toxicity
    Part of recurring concern: Failure to identify clinically significant medication risks
  2. Lack of ambulance service access to GP records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Intervention is limited to patient-safety issues arising from concerns about the GP practice, not ambulance-service matters.

    Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure by ambulance crews to consider possible medication toxicity

Wider context from the report

“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 Naloxone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of ambulance service access to GP records

Wider context from the report

“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 Naloxone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Intervention is limited to patient-safety issues arising from concerns about the GP practice, not ambulance-service matters.

Verbatim wording from the response

“We have investigated the concerns raised by HM Coroner with the GP practice concerned (the Practice). As we are commissioners of primary care in Sussex, we can only intervene in this case in respect of issues that affect patient safety as a consequence of concerns about the GP practice.”

Source location

Response from NHS Sussex
Page 1 · response
Published 15 April 2024

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The GP practice had appropriate systems for sharing records, with no identified technology problems preventing access by healthcare providers.

Verbatim wording from the response

“GP connect allows those with the appropriate access to view the entirety of the GP records. We are assured that the Practice are set up correctly to share their records with other healthcare providers, including SECAmb using the two systems described above.”

Source location

Response from NHS Sussex
Page 2 · response
Published 15 April 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Surrey Heartlands ICB, as SECAmb’s commissioner, may hold information needed to assess ambulance crews’ access to GP records.

Verbatim wording from the response

“NHS Sussex ICB does not know how SECAmb crews access GP records at the scene of a 999 call, and do not know what systems SECAmb use or what their understanding is of what is available to them from the Practice. Surrey Heartlands ICB who are the commissioners for SECAmb may have that information.”

Source location

Response from NHS Sussex
Page 3 · response
Published 15 April 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026