Susan Young

NHS Sussex 
Wicker House 
High Street 
Worthing 
BN11 1DJ 

Ms Penelope Schofield 
Senior Coroner 
County Records Office 
HM Coroners Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

4 April 2024 

Dear Madam 

I write in response to your Regulation 28 report and your covering letter dated 09.02.2024, 
setting out your concerns after hearing evidence at the Inquest touching on the death of 
Susan Mary Young. 

I would like to begin by extending my sincere condolences to Mrs Young’s family.  This 
must have been an extremely difficult time for them, and I hope that my response provides 
them and you with some assurances that NHS Sussex has taken some action to address 
the issues set out in your Regulation 28 report. 

Your matters of concern below have been reviewed and NHS Sussex response is also 
outlined below. 

HM Coroner’s concerns 

The possible toxicity from the Co-codamol tablets was not 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 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 if Naloxone was 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 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.    

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
 The NHS Sussex Digital team reviewed information for the GP practice where Mrs Young 
was registered as a patient in order to find out what technology and what systems they use 
for sharing their records with other healthcare providers.  They advised that the two 
programmes used by the Practice for sharing GP records are SCR (the summary care 
record) and GP connect.  SCRs are an electronic record of important patient information, 
created from GP medical records.  They can be accessed by authorised staff in other 
areas of the health and care systems.  GP connect is a system that allows the GP patient 
record to be viewed and shared between IT systems.   

In addition, the SCR and GP connect are both connected to the spine (safe programmable 
and integrated network environment which filters and forwards information securely across 
a network).  Both SCR and GP connect are live systems and both are accessible to a 
variety of healthcare providers so that if a healthcare professional has a smartcard and an 
appropriate clinical system connected to the spine, the healthcare professional concerned 
will be able to view live information from the GP records from Mrs Young’s GP practice.   

The review also provided the following information: 

The summary care record, as a minimum, allows those with the appropriate access to 
view: 

•  The patient’s current medications 
•  Whether the patient has any allergies 
•  Whether the patient has any sensitivities 
•  Personal Demographic information about the patient. 

The summary care record with additional information allows those with the appropriate 
access to view the above information plus the following: 

•  Any significant medical history past and present 
•  The reason for the prescription of any medication 
•  Anticipatory care information 
•  End of life care information 
• 

Immunisations. 

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. 

In relation to the question of whether and what exceptions there are that might prevent 
their records being shared with other healthcare providers, the Practice confirmed the 
following: 

•  An exception to the Practice being able to share any individual patient’s GP records 
would exist if the patient had refused to agree to their records being shared with 
other healthcare providers and may also exist if no preference either agreeing or 
disagreeing is recorded in the patient’s GP records. At Mrs Young’s GP surgery, 
their records show that 87.6% of their patients have agreed to share their records 
with other healthcare providers. The Practice has confirmed in this case that Mrs 
Young had consented to sharing her records, so they would have been available to 
SECAmb. 

 
 
 •  Upon checking the Practice’s systems, our review found that SECAmb do not 

appear to access record reviews from the Practice as often as other providers do 
with no reviews being recorded for SECAmb by the Practice in December 2022.  
The Practice does have a record of successful reviews by other healthcare 
providers in December 2022 and we can therefore confirm that as far as we are 
able to determine, there were no problems with the Practice’s technology sharing 
the records at that time.   

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.   

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. The Practice agreed with the findings of the NHS 
Sussex Digital Team that forms part of this response. 

I hope that we have provided you with some assurance that NHS Sussex ICB has taken 
steps to address the concerns outlined in your report and that we are continuing to take 
action to prioritise patient safety. 

Thank you for raising this matter with me.   If I can be of any further assistance, please let 
me know. 

Yours sincerely, 

Chief Nursing Officer 
On behalf of NHS Sussex