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 available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.