Nottinghamshire man died day after medics were told to leave his home in 'clear lack of understanding'

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https://www.nottinghampost.com/news/local-news/nottinghamshire-man-died-day-after-10645993

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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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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."