Coroner calls for action over restricted items on mental health wards following tragic death

A jury at Suffolk Coroner’s Court in Ipswich has concluded he died of asphyxia, with a plastic bag over his head, while under in-patient care at a specialist mental health unit in West Suffolk.

The jury were unable to determine his state of mind at the time of his death but concluded contributing factors were insufficient staffing, insufficient observations and one-to-ones, inadequate documentation, no psychologist available and an unclear restricted items policy.

The six-day hearing into Mr Sahota's death at Wedgwood House mental health unit in Bury St Edmunds on September 9, 2019, followed a pre-inquest review last March.

Joshua Sahota, from Newmarket, who died at Wedgwood House in Bury St Edmunds (Image: SUPPLIED BY FAMILY)

Serious concern over the IT programmer's state of mind had led to his admission to the unit, which is located at the West Suffolk Hospital site but operated separately by Norfolk and Suffolk NHS Foundation Trust (NSFT).

Senior coroner Nigel Parsley raised a ‘Prevention of Future Deaths Report’ with Minister for Mental Health and Patient Safety as well as with NSFT.

It was revealed at the inquest that the NHS trust had no definitive local policy as regards allowing plastic bags and some other items within the mental health ward, with staff members having differing practices.

The inquest also heard evidence there was an inadequate care plan in place at the unit for Mr Sahota, and the busy ward was short-staffed on the day he died, with three members of staff instead of six.

The trust had previously been rated as inadequate and placed in special measures in 2017 following review by the Care Quality Commission (CQC).

Craig Knightley of solicitors Tees Law, acting for the family, said: "Joshua’s dad, Malkeet Sahota, and the family are incredibly grateful to the jury for their diligent and thoughtful conclusion, having heard detailed evidence over several days from numerous witnesses.

"It is heartening to see that the jury recognised that Joshua was an intelligent, polite and well-loved young man. Their conclusion substantiates the family’s concerns that multiple serious failings by the trust led to Joshua’s tragic death."

If you need help and support, call the First Response helpline 0808 196 3494 or the Samaritans on 116 123.

Trust's response

Stuart Richardson, chief executive at NSFT said: “I am deeply sorry for Joshua’s death and I am keen to support his family in any way I can.

"I want to assure Joshua’s family that we have improved our internal processes following his tragic death, including making sure there is regular, meaningful, one-to-one time with psychology team members to reduce the chances of this happening to anyone else."

The trust said that a full internal investigation was carried out after Mr Sahota's death.

A new therapeutic observations policy, process and forms was launched in December 2020, following a trust-wide quality improvement project.

Wedgwood House has established a new psychology team which has created capacity for all inpatients to receive regular, meaningful, one-to-one time, and local resuscitation protocols have been updated on all wards.

The trust said: "We will study the conclusion provided at inquest along with the Prevention of Future Deaths report made by the senior coroner to see if there is any further action required, and will update the coroner and family."