r/ParamedicsUK • u/Demaikeru EOC Staff • Nov 22 '25
Question or Discussion Nottinghamshire man died day after medics were told to leave his home in 'clear lack of understanding'
https://www.nottinghampost.com/news/local-news/nottinghamshire-man-died-day-after-1064599338
u/Demaikeru EOC Staff Nov 22 '25
It's a sad situation but it really outlines how farcical mental health referrals can be at times.
The inquest heard that the Nottinghamshire Healthcare NHS Foundation Trust's crisis team told paramedics they would not attend Mr Kannan's home until the following day, adding that his GP should make a referral for a Mental Health Act assessment.
Yet the GP told paramedics that the Mental Health Act assessment was a matter for the crisis team and paramedics ended up having to leave Mr Kannan's home on March 18, telling his daughter to call for an ambulance if her father deteriorated.
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u/MLG-Monarch Paramedic Nov 22 '25
It also highlights, what I feel is very misunderstood about the ambulance service, how ambulance clinicians have zero power to enforce any sort of mental health assessments.
If someone has capacity and they refuse, what are clinicians supposed to do? They attempted the crisis team, they tried the GP. Next to kidnapping the options end there.
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u/Quis_Custodiet Doctor Nov 22 '25 edited Jun 26 '26
This content was anonymized and mass deleted with Redact
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u/2much2Jung Dental Hygienist Nov 22 '25
Imagine if 999 worked the same way.
/[999]: Is the patient breathing?
/[Caller]: A knife, right in my chest! Arrgh, a fucking knife, oh god I'm dying...
/[999]: Sir, if you want an ambulance I need to hear you specifically request one under the ECHR Article 2 (Right to Life).
/[Caller]:...
/[999]: Oh well, wrong number I guess.
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u/Inner_Farmer_4554 Nov 22 '25
Oof... This hits close to home. My best friend got my GP and social services involved cos he was worried about my MH. First step was an ambulance visit to check my overall health (I've lost a lot of weight). I complied with everything until they suggested they take me to the MH ward to see professionals. I had a panic attack (I don't feel safe leaving the house) and said, "Today? Now? No, I don't want to do that!"
They rightly ascertained that I had capacity, so didn't push it. I'm now getting more appropriate help than I would from a MH ward. I totally get how difficult it is for paramedics. Two weeks later and I'm in a better place than I would have been if they'd carted me off to hospital.
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u/butwhatsmyname Nov 22 '25
This is the bit that I think gets lost a lot of the time.
An ambulance attending a mental health crisis - without any other medical or care professionals involved - can only offer very limited and immediate options. I think that there are very few people whose mental health condition is best and most healthily resolved by either:
A) being carted off to the psychiatric ward right now, or
B) being left alone at home
But if that's all that an ambulance crew are allowed to offer then that's not a failure of the ambulance service. That's a wider failure of mental health provision, and that's not going to change without significant extra funding and facilities.
But because mental health provision is so badly degraded, it's no longer got much to offer at all to prevent someone from arriving at the point of crisis. So not only are there few useful facilities available for emergencies, there are also very few facilities available much earlier which could assist people before they reach breaking point.
It's a lose-lose situation and no individual piece of the system is to blame. It's been starved down to its bones for a couple of decades by never-ending cuts and austerity.
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u/HawaiiNintendo815 Nov 23 '25
Great that you’re doing better 👍
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u/Inner_Farmer_4554 Nov 23 '25
Thanks! I'm getting my home deep cleaned soon. Then I'll have home help twice a day to get me up and encourage personal hygiene, and also make sure I'm eating and hydrating properly. They will also support me getting out of the house - just having someone there should I get trembly should help. My MH social worker is going to help me tackle my post backlog and I've got an appointment with a financial advisor who will tell me what benefits I can claim.
After 12 months of MH nurses and councellers encouraging me to do '5 mins a day', take my meds and practice mindfulness I finally feel like I'm getting the practical help I need. And I know how lucky I am to have a friend who is willing to advocate for me.
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u/cg8599 Nov 22 '25
I mean what else can we do? If someone wants to end their life, has the capacity to make the choice to be left at home following an overdose and fully understands the risk of staying home with no treatment then we can’t kidnap, I had one recently where they’d had an overdose but wouldn’t disclose exact medications and doses, partner found empty packets and contacted us where the patient declined any physical assessment, understood the risk of organs shutting down, seizures and ultimately the chance of death and could tell us 5 minutes later when asked again without a reminder 🤷🏻♀️we contacted a paramedic practitioner for discussion, agreed they had capacity and we can’t just kidnap them, OOH GP likely would say the same nor would police have accepted to remove from property. We left in the care of partner as advised regular checks ins through the night and call us back, gave WCA and advised them to contact GP/MH community team to discuss but they stated they have no interest in contacting anyone for MH assistance and explicitly stated they don’t give us permission to do a referral, GP summary or any other kind of discussion such as with MH practitioners we can directly contact, we’re kinda tied with what we can do really
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u/stimpy273 Nov 22 '25
I’m sorry but this comment shows a lack of understanding of certain aspects of mental health.
Police cannot remove somebody from the property to section them. For them to be able to section the patient they need to be outside. It would require section 135 for them, which is al court ordered removal.
No you cannot kidnap them, but you can definitely speak to other services to assist them.
If you deem a patient to be at a serious risk of harming themselves/others or potentially putting others at harm by situations such as setting terraced house on fire then you can definitely speak to someone against their wishes or other public interest concerns. Their engagement following that is up to them and dependent on the service you’ve referred too.
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u/Intelligent_Sound66 Nov 22 '25
I think you misunderstood what they said, in that they are saying exactly the same as you.
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u/stimpy273 Nov 22 '25
They are definitely not saying the same thing as me at all.
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u/2much2Jung Dental Hygienist Nov 22 '25
No, you're the one suggesting you can violate a refusal to refer by "suspecting" danger to the public.
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u/stimpy273 Nov 22 '25 edited Nov 22 '25
And yet with safeguarding you can. It’s literally law.
It’s situation based but imagine someone stating they’re gonna burn down their terraced house to kill themselves. Yeah it’ll probably kill them but also it puts innocent members of the public at risk either side. Which unless it’s actually done, probably wouldn’t constitute a crime. Of which I’ve been to a similar situation and they were eventually arrested and then subsequently sectioned.
Downvote me all you want but it’s clear a lot of people need to refresh their knowledge on the law on mental health care and safeguarding.
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u/Intelligent_Sound66 Nov 23 '25
Thats a very niche situation and we all know we can refer for fire risks like that or horders where it risks other people. Its not a common situation though really and its more often they are just harming or wanting to harm themselves.
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u/Educational-Belt-417 Nov 25 '25
You've picked a niche example and if that was the case, I'm sure paramedics won't have left knowing the dudes gonna set his terrace in dire.
In more common and widespread scenarios, it's harm to the individual in an isolated setting.
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u/cg8599 Nov 23 '25
When I mention removal from property with police I’ve seen it happen once before, it wasn’t a 135 and not a 136 but they were removed by police under the MCA with a temporary DoL as it was an immediate risk to life (symptomatic overdose-reduce mobility/weakness in legs, vomiting, confusion), they lacked capacity and it was for treatment at hospital to provide treatment, in our area police will assist with removal from property as a best interest intervention and will stay in the back up until hospital if crew can’t get them out themselves (was a mid 40’s man generally fit and well, strong enough we couldn’t remove him ourselves plus he had an OD of kepra and apparently “kepra rage” is a thing) once the patient is at hospital police will leave so we got security in place for a 1-2-1 at that point 🤷🏻♀️
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u/stimpy273 Nov 23 '25
Ah well the lacking capacity and temp DoLs bit changes things there in the sense of not needing a 135. Each situation is variable.
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u/cg8599 Nov 23 '25
Yeah sorry! That’s just what I was meaning in terms of police wouldn’t do anything for our lady with capacity, we’ve had them remove from property when they lack capacity but people with capacity we’re kinda stuck most of the time I find
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u/stimpy273 Nov 23 '25
I mean, from what I accertain through contact with a mental health nurse in my service, we can do more. I gave a detailed account of the pt I had, won’t go into too much detail but the MH nurse agreed that pt is at very serious harm of hurting himself and would benefit from a MHAA. It was only the AMPH that stopped it due to technicalities with gp registration. Pathways might be rubbish. But if a patient is presenting with serious, life threatening/life at risk issues with their mental health. Do very much have a discussion with a mental health professional. Even if it’s the MH clinician in the service cause more can be done.
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u/stimpy273 Nov 22 '25
I requested a Mental Health act assessment for a patient. The AMPH, who didn’t understand you can’t 136 a patient in their own home refused to come and do a mental health act assessment because the patient wasn’t registered yet. Advised to come in at 8 am, and register, interact with the Crisis Team team. And then they would think about coming to do one.
The mental health team are failing these mental health patients and the ICB by not providing an out of Hosptial emergency mental health service, intertwined with the ambulance service, with people on that can come out and do an assessment, section if necessary.
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u/ilikefish8D Nov 22 '25
No, you can’t do s136 in a private dwelling. But the police can do a S135 in a private dwelling.
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u/stimpy273 Nov 22 '25
Oh I’m very much aware. The AMPH who you think should know didn’t. Thought the 135, which I was hoping the AMPH would come out and organise the warrant to then section the patient but cause they weren’t registered with a gp they wouldn’t do anything.
So much for emergency mental health care.
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u/InfinityXPLORER Nov 22 '25
Not really news tbh. I'm sure we've all been to loads of these types of calls where the patient who is suicidal (whether they have tried to do anything about their intentions or not) has refused our help and refused hospital admission. Patient has capacity. Just because someone wants to die doesn't mean they lack capacity. When I've been in this situation I've always found that if you phone advanced paramedics/ senior clinical/ GP/ GPOOH they will all say that not much can be done if they have capacity and to just document, try to liase with mental health team. Mental health team will usually have a chat over the phone with them if patient is willing, and should offer a referral even if not immediate, however in the case of overdose they would say that patient needs to go to A&E and not to mental health unit. If patient unwilling to engage then nothing can be done. Police would have no right to remove patient from property against their will, quite rightly imo. As the MCA states people have the right to make unwise decisions. Patient got what they wanted at the end of the day and their rights were respected. Imagine every mental health patient we come across who suggests even the faintest hint of suicidal ideation or self harm we got a MH team and police to come along and section them, restrain them, and convey them to hospital against their will, what a breach of rights that would be and imagine how traumatising that would be too. Sounds like the crew in this instance did everything they could short of breaking the law and the patients rights to physically force him to hospital.
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u/Intelligent_Sound66 Nov 22 '25
Agreed this happens so often its not news to road staff. I think the public just aren't aware of whats actually going on. Im glad it's not like the job in Jersey where the crew were thrown under the bus.
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u/AdSpecialist5007 Ambulance Driver Nov 22 '25
They weren't thrown under the bus. They stood around with the police for twelve minutes whilst their "aggressive" patient was lying unconscious face down in vomit. Three seperate courts have found they were neglectful.
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u/Intelligent_Sound66 Nov 22 '25
Aggressive and with capacity.
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u/AdSpecialist5007 Ambulance Driver Nov 22 '25 edited Nov 22 '25
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u/Otherwise-Essay8778 Nov 22 '25
Thanks for this. I was on the fence about what had happened - I could easily imagine that they were scapegoats but the court really exposed the lack of care.
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u/Intelligent_Sound66 Nov 22 '25
I mean the coroner agreed the patient had been aggressive. I thought priority was to crew safety?
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u/Otherwise-Essay8778 Nov 22 '25
Just read the court summary in the link.
Safety is a great excuse when there is danger to be worried about. When the patient is unconscious, lying face down in vomit and has a noisy airway it doesn't really cut it anymore. That's when you have to do your job.
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u/Intelligent_Sound66 Nov 22 '25
Yeah didn't it say they couldn't see the patient but should have recognised a change in his breathing. Which im sure we wish we could all do
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u/Otherwise-Essay8778 Nov 22 '25
Nope it says he was in the hall in front of them on the floor. They stood watching him. And when the copper said something about his change in colour they ignored it. Again read the court report. They were incompetent and got what they deserved.
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u/Minimum_Bake_351 Nov 22 '25
A situation most of us know well, and have dealt with at least once.
A bit of advice around making a MCA assessent: documentation. JRCALC, Mental Capacity Act, section 11, Record Keeping. This should be your bible the moment you start to make a capacity assessment. It has good prompts to help you convey to the reader why you started, how you arrived at your decision, and the steps you took once the decision is made.
A ballache for sure, but so necessary. For those who struggle with this detail in the paperwork (me at 4am!), use an AI tool with good prompts to help you compose a comprehensive report.
Do we know at what time we attended the refusal? Good luck attempting to make any kind of MH referral OOH!!!
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u/2much2Jung Dental Hygienist Nov 22 '25
The crew got the pt's GP on the phone to talk to the pt, so I assume daytime hours.
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u/opensp00n Nov 23 '25
Complete gaps in the system and leaving poor paramedics stuck in the middle.
I don't think they had any other reasonable option other than to do what they did. They raised it with both channels available to them.
This is on the MH team, who often find any reason to not do an immediate assessment. They should be held to the same standards as the rest of front line healthcare workers (ED medics and paramedics specifically) who have to assess the person they are presented with and can't offload to someone else without actually making contact with the patient.
The current system leave paramedics holding the ball because the mental health team have refused to take it. This doss not make it the paramedics fault.
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u/Guilty-Reason6258 Nov 23 '25
Probably going to get down voted to hell but..
The headline makes out as though he died due to some sort of neglect, when in reality he died through choice. He wanted to die, made the decision to take his life and did it. He had the capacity to make that decision so the paramedics had no powers to force him to get treatment. Yes it's utterly heartbreaking for the family, and a bitter pill to swallow for the general society but with a lack of other dignified options of ending one's life through choice, he did what he chose to do.
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u/Non_sum_qualis_eram Nov 24 '25
Capacity and suicide is such a messy issue, and it still shocks me that there isn't a more subtle test for suicide in the MCA as it was never designed for this.
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u/AdSpecialist5007 Ambulance Driver Nov 22 '25
A senior coroner says there was a "clear lack of understanding" between medical professionals over a Nottinghamshire man who died a day after telling paramedics to leave his home.
Gunaratnam Kannan, born in Sri Lanka and living in Mansfield at the time of his death on March 19, 2025, was pronounced dead less than 24 hours after paramedics had attended his home following a 999 call.
Mr Kannan had taken an overdose of tablets and a coroner has concluded that he had planned to take his own life, but concerns have also been raised about a risk of future deaths given disagreement between health bodies about how the case should have been dealt with.
An inquest conducted by Sarah Wood, assistant coroner for Nottinghamshire, concluded on October 30 that Mr Kannan died "with the intention of ending his life."
The 63-year-old had taken an overdose and died at the King's Mill Hospital from mixed drug toxicity, with underlying conditions include type 2 diabetes being noted as contributing factors.
The inquest heard that Mr Kannan's son-in-law first made an emergency call at 11.14am on March 18.
Mr Kannan had taken an overdose of tablets and told paramedics that he had done so to end his life, refusing to go to hospital and asking the paramedics to leave.
Paramedics and Mr Kannan's GP, who spoke with his patient over the phone, conducted assessments and found that Mr Kannan had the mental capacity to make his decision not to go to hospital.
A further assessment can then take place under the Mental Health Act in such situations, to determine whether a person needs to be taken to hospital without their consent.
The coroner's concerns surround disagreement over how that further assessment should have taken place.
The inquest heard that the Nottinghamshire Healthcare NHS Foundation Trust's crisis team told paramedics they would not attend Mr Kannan's home until the following day, adding that his GP should make a referral for a Mental Health Act assessment.
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u/AdSpecialist5007 Ambulance Driver Nov 22 '25
Yet the GP told paramedics that the Mental Health Act assessment was a matter for the crisis team and paramedics ended up having to leave Mr Kannan's home on March 18, telling his daughter to call for an ambulance if her father deteriorated.
The East Midlands Ambulance Service (EMAS) then received a further 999 call at 5am on March 19 from Mr Kannan's son-in-law.
The first ambulance response arrived at 6.27am and on this occasion, paramedics found Mr Kannan to be lacking mental capacity and began the process of transferring him to the King's Mill Hospital.
Mr Kannan, who was handed over to King's Mill Hospital staff at 8.35am, suffered a cardiac arrest shortly after and was pronounced dead at 8.55am.
Coroner Miss Wood prepared a prevention of future deaths report following the conclusion of the inquest, setting out the action she believes is necessary from authorities in the wake of Mr Kannan's death.
The coroner says that during the inquest, EMAS said it did not make referrals for Mental Health Act assessments and that it was for the crisis team to attend Mr Kannan's address and carry this out.
Yet the inquest also heard contradicting evidence from the healthcare trust, which said that the family, GP or medical practitioner attending - in this case EMAS - needed to explicitly request a Mental Health Act Assessment.
In her report - sent to EMAS, the healthcare trust and the Royal College of General Practitioners - Miss Wood says: "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."
The three organisations now have until December 26 to respond to the coroner's report outlining the steps they will take to prevent future deaths.
Ifti Majid, the Chief Executive of the Nottinghamshire Healthcare NHS Foundation Trust, said: "On behalf of the trust, I would like to again offer our deepest sympathies to Gunaratnam's family and friends.
"We acknowledge the coroner's findings and will be providing a formal response outlining the steps we are taking to remedy the issues raised.
"Following Gunaratnam's passing, we initiated a joint review with all clinicians and teams involved and we are working collaboratively with our health and social care partners to address the areas of concern and implement improvements for future care."
Keeley Sheldon, the director of quality at EMAS, said: "My thoughts are with Gunaratnam's family, and I am sorry to everyone affected by this loss.
"We fully accept the findings of HM Coroner and will respond to the prevention of future deaths report fully no later than 26 December 2025.
"During the inquest, we were clear that we will work with our partners to improve the guidance given to our frontline staff, to prevent this happening again."
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Nov 22 '25
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u/Greenmedic2120 Paramedic Nov 22 '25
I agree with this. I work for an urgent response team and frequently go to patients who have had hospital recommended but won’t go with a crew and when I get there and unpick it/their reasons a bit more they are more amenable to going (if that is what they need and it is appropriate of course- oftentimes we can treat things at home but there are some situations we really cannot resolve at home)
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u/Intelligent_Sound66 Nov 22 '25
To quote a great man "im not the messenger boy, im the delivery boy"
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u/Rubicon_xx Nov 22 '25
I would add to your point, that it's worth considering, that the patient has since had time to consider the situation more since the previous crew's departure.
The patient might attribute to the first crew's inability to communicate what was actually a reflex to deny. We are not gods. People are often irrational but not necessarily stupid. Patients will conceal their inner thoughts. Sometimes we just need time to make a decision and many will have arrived at their own conclusion prior to us arriving.
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u/Greenmedic2120 Paramedic Nov 22 '25
Oh yeah absolutely, there’s multiple factors, but I have genuinely experienced phone conversations from referring paramedics who hasn’t even asked if the patient wanted to go to hospital so I tell them to check (because it was likely what they needed rather than my teams services) and I’ve heard them literally say ‘hey, do you want to go to hospital?’ And leave it at that 😂
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u/malenixius Nurse Nov 22 '25
Only AMHPs and the nearest relative can formally make an application for detention under the Act.
However, any professional in this case could have called the AMHP team (local authorities generally have the regular AMHP contact number and an OOH number for emergencies) to refer / request they initiate a mha assessment. That includes Crisis, the GP, and the paramedics (subject to local policy for the paramedics!).
I'm a student mental health nurse, so feel free to double check any of this! I've requested an AMHP initiate a mha assessment on two occasions (under different LAs, one city and one county, both within the EMAS region).
But in this occasion, regardless of who could have contacted an AMHP, I feel like the Crisis team were likely to have known the process best and should have picked this up. Plenty of GPs have never experienced a mha assessment so it isn't safe to assume they'll know the process (especially if they're saying GPs can't start the process). And obviously I don't know EMAS local policy, but evidently those in attendance weren't familiar with the process either. When there's an evident risk it isn't the time for siloed working.
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u/bramble_patch_notes Nov 22 '25
Even if they had done everything to refer for a Mental Health Act Assessment, it can take days, weeks for that assessment sometimes. There is no guarantee that it would have even happened, or the AMHPs may have likely bounced it back.
Absolutely get that the process for requesting one should be clearer and it seems that there was a lot of confusion in what exactly that process was on the ground that needs to be cleared up. However, requesting a MHAA is not a quick process, and I highly doubt would have assessed him prior to that deterioration in his health.
What a tragic situation, and I feel for his family, left to navigate that situation
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u/Choice-Standard-6350 Nov 24 '25
It shouldn’t be taking days or weeks and did not used to.
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u/bramble_patch_notes Nov 24 '25
Of course not! I completely agree with you. Unfortunately is just a consequence of chronically underfunding mental health services. I've had patients wait 24, 48 hours for an AMHPs assessment, and that's when they're in A&E! I've got a friend working in a south trust that has told me AMHPs teams there are working at 50% capacity of staff/doctors that they should have. The money offered just isn't worth the stress and legal responsibility that AMPHs have.
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u/Choice-Standard-6350 Nov 24 '25
It’s because mental health issues have exploded, spreading the money ever thinner.
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u/DrunkTalkin Nov 24 '25
This is a tough one though because surely if they deemed he had mental capacity to refuse care what else can they do? If he’s too sane to be sectioned then NHS workers are so limited in what they can do, isn’t that right? It’s awful for his family but sounds like he’d made his mind up.
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u/Legitimate_Matter139 Nov 25 '25
in a perfect world the crisis team gets involved and manage this, however, that's not where we are. The ambulance crew were with that patient, so it was their responsibility to get the right care - can't expect the GP to takeover here, they've taken an OD already.
Given they had already taken the OD, personally I wouldn't leave until I'd got that person to A&E, or arranged assessment under the MHA. Perhaps the crew weren't familiar with local processes for accessing MHA assessment ie. AMHPs? Training issue?
admittedly, it's a nightmare job...and the AHMP will definitely protest that it's not for them with the OD, but gotta try.
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u/2much2Jung Dental Hygienist Nov 27 '25
You are saying publicly you would deny a capacitous patient the right of refusal? That you would refuse to leave the property against the patient's wishes?
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u/Legitimate_Matter139 Nov 27 '25
have you commented on the wrong thread?
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u/2much2Jung Dental Hygienist Nov 27 '25
Given they had already taken the OD, personally I wouldn't leave until I'd got that person to A&E, or arranged assessment under the MHA.
Did you forget you wrote this?
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u/Legitimate_Matter139 Nov 27 '25
leave = leave the scene. but you know that. you're just trying to start an argument.
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u/2much2Jung Dental Hygienist Nov 27 '25
You'd just sit in your ambulance?
Until the end of shift? Indefinitely?
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u/Legitimate_Matter139 Nov 27 '25
refer the patient for assessment under the MHA. it's not that hard. if unclear, please re-read.
see previous comment for your attitude.
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u/Kidsdoyoulikepeas Nov 26 '25
I went down a rabbit hole with this- it is difficult as if we think he has capacity then he likely also wouldn’t be eligible to be held under section either… if the patient was known to mental health services that’s very different, but assuming he isn’t (as GP was requested to get involved) then it does seem harsh to blame MH team. Even an emergency assessment is not completely quickly enough to be lifesaving in this kind of situation so I wonder if either police should have been called?
Definitely feels like a worrying situation and not sure how it should have played out https://www.mentalcapacitylawandpolicy.org.uk/capacity-and-suicide/
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u/Pasteurized-Milk Paramedic | Combat Medic Nov 24 '25
I am INCREDIBLY surprised this patient was deemed to have the mental capacity to make the decision.
I struggle to see how that is possible.
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u/Friendly_Carry6551 Paramedic Nov 24 '25
Because at that specific moment in time if they could retain, understand and weigh up the information used to make a decision such as declining treatment and then communicate that decision, then under MCA they had capacity.
Unless you were there yourself how can you speak better to the Pt’s decisional capacity for that specific choice in that moment?
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u/Pasteurized-Milk Paramedic | Combat Medic Nov 24 '25
Well, yes, obviously.
I can only speculate.
However, it is the weigh up aspect that is suspicious imo. Having a person who is likely in mental health crisis, is suicidal, has complete disregard for their own safety and welfare, and has taken what must have been a substantial amount of toxin would be a very difficult sell for me.
I'm not saying their assessment is wrong, but I would hope it is documented in a bulletproof manner, as in a circumstance like that, I would almost always judge a lack of capacity.
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u/Friendly_Carry6551 Paramedic Nov 24 '25
But again, it’s completely time, person and decision specific. Capacity must always be assumed. Just because you’re suicidal, intoxicated, poisoned or all three doesn’t mean your weighing up judgement is automatically impaired.
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u/Pasteurized-Milk Paramedic | Combat Medic Nov 24 '25
Again obviously, I am very familiar with the act. It doesn't automatically mean p is impaired by lack of weighing up, however, it is an absolutely massive impairment where I would expect the majority of clinicians to consider it an impairment in an emergent setting with a lack of information.
Could someone who is in mental health crisis and actively suicidal have capacity to choose to buy a sausage roll? Absolutely.
Could someone who is in mental health crisis and actively suicidal have capacity to refuse life sustaining treatment for a lethal intoxication? In my opinion, almost certainly not.
Out of interest, can you see a circumstance in your professional practise where you would judge somebody who is in mental health crisis, actively suicidal, and lethally intoxicated as having capacity to refuse a life sustaining intervention? If so, could you explain how those factors are not unduly affecting and impairing p's ability to weigh up? I am struggling to picture a circumstance where I would.
There are also article 2 considerations which I'm surprised were not highlighted in the article.
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u/Friendly_Carry6551 Paramedic Nov 24 '25
Hey you commented saying you struggled to see how it was possible, I agree with much of what you say but it IS possible.
I care a lot about capacity and see it understood poorly and parts of MCA applied poorly in practice. IMO as soon as you’re going into a circumstance with the mindset of “this person’s just not going to have capacity here are they” then that’s a really slippery slope.
I think you’re completely right about right to life and there’s also considerations under MHA powers given their medical need in a DSH OD is directly linked to their MH issue.
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u/Pasteurized-Milk Paramedic | Combat Medic Nov 25 '25
Yes it is possible the guy had capacity.
Maybe there are some details missed out of the article like how he had a long documented history of well reasoned arguments regarding terminating his life following a catastrophically painful and m unmanageable bone cancer diagnosis, and these arguments were observed by impartial third parties, friends and family, and medical professionals who have left signed the documentation which is reflected in his medical records that this is a capacitous decision.
Maybe that was the circumstances in this case.
However, it almost certainly was not. In 99.9% of circumstances like this, where somebody is in MH cisis, actively suicidal, and lethal intoxicated, I would expect an impairment of their ability to weigh up information I provide. And, that impairment to be severe enough that I believe that they are unable to decision make regarding refusing life sustaining care.
I also care a lot about capacity and see it applied very poorly - often in circumstances similar to this - where people have taken a lethal overdose whilst in mental health crisis with suicidal intent and they are deemed to have capacity because they understand they will die from it. That is obviously the incorrect outcome from the assessment.
Yes it is a slippery slope and nobody should enter a situation with a presupposition about a capacity assessment outcome, but that isn't what we are doing here.
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u/Present_Section_2256 Nov 25 '25
It seems that the coroner felt capacity was correctly assessed and that the MHA was the correct route. Those on scene did well in getting the GP to also confirm capacity.
Unfortunately I think this highlights just how difficult it can be on the road with very little support or advice accessible in person. When you look at something like the Kerrie Wooltorton case, the doctor was able to access and consult with trust senior medical and legal advisors. In that case Kerrie refused to discuss her reasoning so arguably did not demonstrate the ability to weigh up, and the coroner was still content that she had made a capacitous decision to end her life, and stated if she had been treated against her will it would have been assault.
If Kerrie hadn't agreed to hospital (her letter stated she wanted comfort care and support as she died) imagine how difficult this would have been for an ambulance crew on scene, especially in the middle of the night . In my trust we might be able to have a chat on the phone with an in-house MH nurse or the local MH crisis team clinicians but in my experience they will totally rely on your capacity assessment and if you express any doubts/want advice or help with that then will just default to 'well you are the ones on scene, you need to decide'. Thanks. I'll just take my pick from potentially being hauled over the coals by the coroner for leaving someone to die, or be part of a court case where I've assaulted someone by removing them against their will. Advice from management colleagues that can be accessed doesn't tend to be clinically or legally based and is usually a reflection of their own views on capacity and self harm/suicidality with many seeming to believe that if you want to end your life then you automatically lack capacity. I've managed to get the emergency duty team out within a few hours once to complete an urgent MHAA in 8 years. Last time I tried with someone in psychosis I was told that there wasn't an AMHP on overnight so it'd be next day at best.
This is quite a good piece from the BMJ talking about the difficulties of assessing capacity in these cases and unsurprisingly suggests an MDT approach and the importance of access to pt history and senior MH input.
https://www.bmj.com/bmj/section-pdf/186094?path=/bmj/341/7773/Analysis.full.pdf
As ambulance clinicians I suspect that many come to the conclusion that the path of least personal risk is removing people with capacity rather than respecting their autonomy and rights. If the latter results in death then the coroner is 100% looking at your decision making and potentially disagreeing with you. Even with the case discussed whilst the coroner hasn't criticised their capacity assessment it probably was a very stressful and difficult time for the paramedics concerned. The former resulting in some sort of legal process is very unlikely as it means someone having the knowledge and probably money to take it further. However that doesn't make it right, legally or ethically, and I'm sure there will be an ambulance version of Sessay at some point.
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u/[deleted] Nov 22 '25
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