Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0553, written 31 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2025 |
|---|---|
| Reference | 2025-0553 |
| Deceased | Gunaratnam Kannan |
| Coroner | Sarah Wood |
| Coroner area | Nottingham and Nottinghamshire |
| Category | Emergency services related deaths (2019 onwards) · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, Nottinghamshire Healthcare Trust (NHCT) The Chief Executive, East Midlands Ambulance Service (EMAS) The Royal College of General Practitioners 1 CORONER I am Miss Sarah Wood, Assistant Coroner, for the coroner area of Nottinghamshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 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. 4 CIRCUMSTANCES OF THE DEATH 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 information he became aware of after Mr Kannan’s death. , this 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. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows – • 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. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 26th of December 2025. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Family. 2. All IPs I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 30th of October 2025 Miss Sarah Wood
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Confidential Miss Wood Assistant Coroner for the Coroner Area of Nottinghamshire Trust Headquarters 1 Horizon Place Mellors Way Nottingham Business Park Nottingham NG8 6PY 5 December 2025 Dear Miss Wood Re: Report regarding the case of Mr Gunaratnam KANNAN deceased I am writing in response to the concerns you raised following the inquest into the tragic death of Mr Gunaratnam KANNAN, which concluded on 30 October 2025. At the outset, please allow me to express my sincere condolences to Mr Kannan’s family. I understand that you will share this response with them, and I hope it provides reassurance of our commitment to learning and improvement. The East Midlands Ambulance Service (EMAS) exists to deliver safe, effective, and compassionate care, while fostering a culture of continuous improvement and collaboration across the healthcare system. I acknowledge the matters of concern highlighted by His Majesty’s Coroner and offer the following clarifications and commitments. Matters of Concerns raised on 30 October 2025 • Lack of joint agency working/policy work on the Mental Capacity Act (MCA) Assessments and Mental Health Act (MHA) Assessments setting out the roles and remit of service providers. I recognise the importance of clear pathways and joint working between agencies. While local authorities can accept referrals for MHA assessments, the established expectation is that ambulance crews seek the least restrictive intervention first. This means referring patients to local mental health crisis teams for initial assessment and support before considering formal detention under the MHA. Respond | Develop | Collaborate Ambulance crews are not mental health specialists and therefore cannot determine whether a statutory MHA assessment is required. At present, EMAS does not have formalised referral pathways with local crisis teams; however, we are actively working with mental health trusts to develop and implement these pathways. On a national level, EMAS is engaged in a workstream through the Quality, Improvement, Governance and Risk Directors Group to address challenges in managing suicidal patients who are judged to have the capacity to refuse conveyance to hospital and seek to provide clear guidance and escalation for our frontline clinical crews. Locally, EMAS participates in a quarterly Right Care Right Person Meeting led by Nottingham and Nottinghamshire Integrated Care Board, alongside system partners, to review clinical and operational responsibilities and identify gaps in service provision. Following the inquest, a wider multi-agency group has been convened to specifically consider how to strengthen decision-making and pathways between agencies when considering the mental health act and the mental capacity act. To support this, on 8 January 2026 EMAS will undertake an After Action Review with all parties involved in this incident to reflect on what happened, why it happened, and what can be learned to improve future practice. • Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments. EMAS has a robust education programme to support clinicians in conducting mental capacity assessments. All clinical staff receive relevant training as part of their core qualification (e.g., paramedic courses), supplemented by safeguarding education, which includes MCA principles within a rolling statutory programme. Supporting tools such as non-conveyance checklists and MCA prompts are embedded within our patient record system to guide staff in practice. Furthermore, all front-line crews undertake Mental Health Awareness training every two years, covering statutory detention processes, roles, and current pathways. This training is under review for January 2026, and we will seek input from Mental Health Trust partners to ensure alignment with formalised pathways for MHA assessments. I trust this response demonstrates our commitment to addressing the concerns raised and to improving joint working, training, and patient care. Respond | Develop | Collaborate Page 2 of 3 Please do not hesitate to contact me if I can be of any further assistance in this matter. Yours sincerely Chief Executive Respond | Develop | Collaborate Page 3 of 3
Nottinghamshire Healthcare NHS Foundation Trust Highbury Hospital Highbury Road Nottingham NG6 9DR 5 January 2026 Private and Confidential HM Assistant Coroner Wood Dear Ms Wood Regulation 28 Response: Mr. Gunaratnam Kannan I write in response to the inquest which was concluded on 30 October 2025 into the death of Mr. Kannan. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Mr. Kannan. Please find below the Trust response in relation to the relevant matters of concern and actions taken. Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments. As a response to the incident there was a learning review with bespoke training for the Clinical Access Line and the Crisis Resolution Home Treatment team led by the Trust’s Mental Health Legislation team around use of the Mental Capacity Act on 7.10.2025. Two flow charts were also developed (Appendix A and B) to help support staff in what considerations need to be given regarding mental capacity upon receipt of a call such as that in the case of Mr. Kannan. This includes when liaising with EMAS to ensure that there is significant consideration on how a person’s mental health and consumption of substances may alter their thinking and capacity. These have been shared with all staff and are displayed in team offices for quick reference. The process for referring for Mental Health Act assessments is held by the Approved Mental Health Practitioners (AMHP) who are part of the Local Authority. There is a clear process and pathway already in place (Appendix C). Highbury Hospital, Highbury Road, Nottingham NG6 9DR All clinical staff members must attend the Trust Mental Capacity Training on a three yearly basis. Key topics covered as part of this training are: • Consent • The 5 principles of the Mental Capacity Act • Mental capacity assessments • The ‘best interests’ checklist and making best interest decisions • Restraint in relation to the Mental Capacity Act • IMCAs and planning for the future (including making Lasting Power of Attorneys, advance statements, advance decisions to refuse treatment, and advance decisions to refuse life sustaining treatment) The training has been reviewed and is considered to capture all required fields and be of good quality. Compliance is monitored as part of team essential training, and this will continue for all clinical teams moving forward. In addition, the Mental Health and Legislation team provide a further Deprivation of Liberty (DOLs) training session for those staff members working in areas that DOLs applies to; and there are monthly Mental Capacity Act Documentation Workshops on Microsoft Teams for anyone to attend, and these focus on the requirements of the law in terms of sufficient information for consent, capacity assessments and best interests decisions. 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. There is a clear process set out by the Approved Mental Health Practitioners in relation to requesting Mental Health Act assessments across Nottingham City and County which is included at Appendix C. EMAS agreed to lead on an After-Action Review following the conclusion of the inquest, which key Nottinghamshire Healthcare NHS Foundation Trust employees and managers would be invited to and agreed to participate in. This is to be completed on 8 January 2026. In addition, prior to the commencement of the inquest, Nottinghamshire Healthcare NHS Foundation Trust contacted the Safeguarding Adults Board (SAB) to make them aware of the concerns that the coroner had made organisations aware of when gathering the evidence of the case. The request was for SAB to facilitate a workstream forum involving all key agencies within the Nottingham area, with the aim to come together and agree a joint working mechanism / protocol setting out the roles and remits of service providers in the context of assessments via both the Mental Capacity and Mental Health Acts. The first meeting took place on 3 December 2025, with the plan to meet again on 7 January 2026. The initial meeting provided opportunity to discuss the case of Mr. Kannan and the current practices being followed by each agency in attendance. EMAS informed the group that this is not an issue limited to the Nottingham jurisdiction but recognised by ambulance services to be a national concern with previous prevention of future deaths notifications having been issued relating to the consideration of capacity in scenarios where a patient is declining to attend hospital for emergency treatment following lethal consumption of substance. A National workstream is also being convened by Ambulance Services to look at this in more detail. The group was informed that the national meeting was later on 3 December 2025 and that a potential outcome will be a new national pathway. It was agreed that the national work may supersede the work of this newly established local group, but that there may be additional action to be take in the meantime whilst Highbury Hospital, Highbury Road, Nottingham NG6 9DR waiting for the outcome of the national discussion. The plan from this first meeting then was for all agencies to share their local internal pathway and protocol in terms of response and remit and EMAS to provide an update on the national forum at the next meeting in January 2026. The Trust has taken the concerns highlighted by the coroner in this case very seriously and agrees fully that, based on the evidence provided by agencies involved in this case at inquest, there is a need for joint working to ensure all clinicians working under such difficult circumstances are supported to make decisions confidently and in the best interests of the patients involved. I hope that this response provides you, Mr. Kannan’s family and the other parties involved with reassurance in terms of the ongoing plans to improve these important areas of patient care moving forward. Yours sincerely Chief Executive Officer Highbury Hospital, Highbury Road, Nottingham NG6 9DR
Dr Jamie Hynes FRCGP Vice Chair Member Standards Miss Sarah Wood Assistant Coroner for the coroner area of Nottinghamshire 6 January 2026 Dear Miss Wood Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Gunaratnam Kannan Thank you for asking us to comment on the matters of concern following the sad death of Mr Gunaratnam Kannan who died on the 19th of March 2025. Apologies that there has been a delay in response as the notification was received by my predecessor and came to my attention after my appointment to this role in December. Our sincere condolences go to his family and friends given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Mr Kannan’s loved ones. You have two matters of concern relating to this tragic death. • 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. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research and advocating and representing the College and its 56,000 members. General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. There are 5 areas of capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and these are supported by twenty-two Clinical Topic Guides. The Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III area of Mental Health Act assessment is covered in the Mental Health Clinical Topic guide and in this case the two areas of a GP’s role relates to: • coordinate care with other organisations and professionals (for example, ambulance service, community mental health teams, social workers, secondary care, voluntary and community sectors, social prescribers and police) • follow agreed protocols, including as part of the Mental Health Act and the Mental Capacity Act where appropriate. Service issues are also covered during GP Training within the urgent and unscheduled care topic with ‘Dangerous Diagnoses’ being outlined, such as suicide risk, mental health crisis and the importance of communication with emergency services. Strategies for ensuring effective and appropriate communication and escalation of care to other service providers are also covered. As well as the GP curriculum, the RCGP makes available a Mental Health toolkit for our members which includes an area on Crisis, self-harm, and suicide with links to the NICE guideline CG136 with recommendations relevant to this case and the Mental Health Act. Although the RCGP does not have a role in the regulation of General Practice service provision, the regulator CQC has made specific reference to areas of mandatory training considerations in General Practice (GP myth buster 70) . This specifically mentions that they expect to see evidence of training for Mental Capacity Act and Deprivation of Liberty Safeguards from GP Service providers, which have relevance to the challenging scenario facing professionals and Mr Kannan’s family. Training is provided via external sources, for example e-Learning for Health, CPD UK and other platforms. Re-examining specific issues of Mr Kannan’s case is beyond the remit of the College, but it highlights the need for Nottinghamshire HCT to reassert their processes of acceptable medical practitioners instigating urgent referrals to enable best outcomes and prevent future deaths in similar circumstances. Having reviewed the Nottinghamshire Healthcare NHS Foundation Trust mental Health legislation (MHL) Policy and Procedure manual, we believe that more clarity on the policy is required and further training opportunities for Nottinghamshire Healthcare NHS Foundation Trust staff. We have concerns around the lack of priority given to urgent mental health services and for individuals with serious mental health concerns to receive timely and effective crisis management. Mental health teams, often within a single Mental Health Trust, need to be integrated to support a personalised care approach. It would be worth NHS England considering how mental health providers commission services to enable this to be developed in all policy and procedures for NHS Mental Health Trusts. We hope that the reflective processes are in place to ensure such a difficult outcome would not be repeated if a similar scenario for other patients developed in future. Metformin and Metformin. The current toxbase advice would or more metformin should be referred for medical We recognise that there is also an issue around communication between the GP and the paramedic who attended initially. There would be a significant difference in response between an overdose of suggest that ingestion of tablets of metformin (the assessment. For a 70kg man this would equate to a threshold of quantity of tablets is well above this threshold). The peak levels are reached after around 7 hrs of ingestion, and this then increases the metabolic consequences of lactic acidosis and tablets of indapamide tablets would have also been a toxic dose death. The ingestion of (above the threshold of patient. Clear risk as suggested by the paramedic was identifiable from either of the medications taken in overdose. ) further increasing the risk of harm and toxicity to the System pressures create decision making risks and GPs are taking on more work due to these pressures, with increasing numbers of ambulance paramedic calls supporting patients to remain in the community wherever possible. It is important to recognise that GPs require dedicated time, resources and connected clinical systems to support decision making, especially where the decision making is complex and involves multiple agencies. Many of these calls are made whilst GPs are performing other patient-facing and administrative duties. As such, this risks impacting on effective communication between professionals. There is an opportunity to address the System aspects of the referral processes, to alleviate the workload pressures sufficiently to best serve the complex decision-making GPs engage in, in the hope of preventing future deaths in similar circumstances. Once again, our condolences go to Mr Kannan’s family and friends, and we thank you for extending the date for this response to reach you. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development. Yours faithfully Vice Chair Member Standards
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