Mr Gunaratnam Kannan · Prevention of Future Deaths report

On the 3rd of April 2025, I commenced an investigation into the death of Mr Gunaratnam Kannan. The investigation concluded at the end of the inquest on the 30th of October 2025.
The conclusion of the inquest was suicide.

On the 18th of March 2025 at 11.14am East Midlands Ambulance Service (EMAS) received an emergency call from Mr Kannan’s son in law. He reported that Mr Kannan was awake and breathing and that he had taken an overdose of tablets. At 11.29am EMAS dispatched a paramedic led double crewed ambulance and they arrived at the address at 11.39am.
Paramedics from EMAS were met at the address with Mr Kannan’s daughter and son in law. The paramedics were informed that he had taken approximately ████████ Metformin and approximately ████████ Indapamide tablets. Mr Kannan informed the paramedics that he had taken the tablets to end his life and did not want to continue living.

Mr Kannan was refusing to go to hospital. The paramedics attending conducted what they described as a 2 stage mental capacity assessment. The crew deemed him to have capacity and therefore could not in their opinion force him to go to hospital with them. The paramedic made contact with Mr Kannan’s GP, who spoke with Mr Kannan directly and reiterated the risks of not receiving hospital treatment. The GP believed that a mental capacity assessment had been carried out by the paramedics and therefore advised them to make contact with the crisis team to review the patient urgently. The GP also confirmed he had undertaken a mental capacity act assessment and that Mr Kannan had capacity to make his decision not to go to hospital. It was the GP’s understanding that he was told Mr Kannan had taken ████████ tablets of Metformin not ████████, this information he became aware of after Mr Kannan’s death.

The paramedic made contact with the clinical access line (CAL) at NHCT who advised that they would not attend until the next day and that they should ask the GP to make a mental health act assessment referral. The paramedic advised them that Mr Kanna would not survive. The paramedic made a further call to the GP who repeated his previous advice that it was a matter for the crisis team. The paramedics tried one more time to persuade Mr Kannan to go to hospital but he refused and asked them to leave. They provided advice to his daughter that if he deteriorated they should call for an ambulance and they left the property as this was Mr Kannan’s wish.
At 5am on the 19th of March 2025 EMAS received a 999 call from Mr Kannan’s son in law reporting that his father in law had taken an overdose of tablets and was suffering with low level breathing. This call achieved a category 3 disposition.

At 6.10am on the 19th of March 2025 EOC received a request through the electronic gateway from NHS 111 for Mr Kannan. Information passed to them was that Mr Kannan required an emergency ambulance response for sepsis. At 6.17am a paramedic led double crew was dispatched and at 6.45am the dispatch officer allocated a technician led double crewed ambulance. At 7.11am the dispatch officer allocated a paramedic working on a fast response vehicle. At 7.14 the dispatch officer allocated a paramedic working on a fast response vehicle. The first ambulance response arrived at 6.27am.

Mr Kannan was assessed as actively suicidal, he appeared confused and had a limited level of consciousness. It was on this occasion that EMAS confirmed Mr Kannan was assessed as lacking mental capacity, and that this was due to an impairment of brain function. He was unable to understand, retain, or weigh information appropriately, and could not effectively communicate a decision.

Due to the difficulty in removing Mr Kannan from the property the hazardous area response team (HART) were called to assist in removing him so that he could be taken to hospital. They left the property at 8.01 and arrived at Kings Mill Hospital at 8.14 and was handed over to hospital staff at 8.35. Mr Kannan suffered a cardiac arrest shortly after and was pronounced deceased at 8.55am on the 19th of March 2025.

• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.

I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.

In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.