A coroner has called for action after a woman died accidentally from taking too many painkillers.

Penelope Schofield, senior coroner for West Sussex and Brighton and Hove, published a prevention of future deaths report after the inquest of Susan Young ended on January 31.

Susan, 57, was found to have died at her home in West Sussex on December 20, 2022, after taking "too many tablets over a short period of time".

The coroner wrote in the report: "Susan had been feeling unwell and had been prescribed antibiotics for an ear infection and co-codamol tablets as pain relief.

"Sadly due to the pain she was in Susan took too many tablets over a short period of time and this led to a fatal toxicity.

"There was no evidence that this was a deliberate act to end her life."

READ MORE: Hospital visitors allowed back after major incident was declared

The coroner said that there was a "missed opportunity" for ambulance crews to treat Susan as a result of the lack of integration between healthcare providers.

The coroner's report read: "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."

The report was sent from the coroner to the Chief Executive NHS Sussex Integrated Care Board.

The coroner said "there is a risk that future deaths could occur unless action is taken".

The full report can be found here https://www.judiciary.uk/prevention-of-future-death-reports/susan-young-prevention-of-future-deaths-report/.

Responding to the report, a representative for NHS Sussex, which commissions primary care in the county, said that there are two systems in place which allow the GP practice to share records with SECAmb.

These systems were working at the time of Susan's death and would have been able to give important details including her medications.

A spokesman for NHS Sussex said: "NHS Sussex ICB does not know how SECAmb crews access GP records at the scene of a 999 call, and does not know what systems SECAmb use or what their understanding is of what is available to them from the practice.

"Further enquiries of SECAmb may be needed to understand their systems, processes and their understanding of what is available to them in order to fully address HM Coroners concerns.

"Our investigations with the GP practice have found that they have the appropriate systems in place to enable other healthcare professionals to remotely access the GP records that are held by them."