Skip to content
recurance

Susan Young

9 Feb 2024 · Coroner Penelope Schofield · West Sussex, Brighton and Hove

The coroner's concerns

  1. 1. missed opportunity to treat Co-codamol toxicity

    “The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs [name redacted] following a 999 call”
  2. 2. missed opportunity to administer Naloxone

    “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 [name redacted] would have survived”
  3. 3. lack of GP record access

    “The Ambulance Service was not aware that Mrs [name redacted] had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Susan Young · Recurance