A jury at Suffolk Coroner’s Court in Ipswich has delivered its conclusion in the tragic case of a Newmarket man who died while under in-patient care at a specialist mental health unit in West Suffolk. The six-day hearing followed a pre-inquest review last March.
HM Senior Coroner for Suffolk, Nigel Parsley, led the investigation into Joshua’s death on 9 September 2019. At the lengthy inquest, the jury concluded that 25-year-old Joshua Sahota died at Wedgwood House mental health unit in Bury St Edmunds as a result of asphyxia by deliberately placing a plastic bag over his head and using a bed sheet around his neck.
Lack of adequate risk assessment
The inquest heard that Joshua was a quiet young man who kept to himself. Staff only got to know him superficially, which limited their ability to assess the risk he posed to himself. Despite being classified as a high suicide risk throughout his admission, no effective measures were implemented to ensure his safety.
Joshua had previously attempted suicide by deliberately driving a car off a bridge onto the A14 near Newmarket. The jury was unable to determine his state of mind at the time of his death but highlighted several contributing factors including:
- Insufficient staffing
- Inadequate observations and 1-to-1 supervision
- Poor documentation
- Lack of access to a psychologist
- Unclear restricted items policy
Prevention of future deaths report issued
The coroner has raised a ‘Prevention of Future Deaths Report’ not only with the Trust but also directly with the Minister for Mental Health and Patient Safety. This rare step underscores the severity of the restricted items issue at a national level.
Joshua’s admission to wedgwood house
Joshua was admitted to Wedgwood House, located at the West Suffolk Hospital site in Bury St Edmunds. Although the hospital site is under West Suffolk Hospital NHS Foundation Trust, Wedgwood House is managed by the Norfolk and Suffolk NHS Foundation Trust.
The Trust was previously rated as inadequate and placed under special measures in 2017 following a Care Quality Commission (CQC) review. Since November 2018, the Trust has faced 21 Mental Health Act monitoring visits, resulting in 96 required actions.
Unclear policies and inadequate staffing
The inquest exposed that the NHS Trust had no clear local policy regarding the possession of plastic bags, belts, shoelaces, and similar items on the mental health ward. Staff members followed inconsistent practices, leading to uncertainty around which items were permitted.
Additionally, the unit’s care plan for Joshua was deemed inadequate. On the day of his death, the ward was short-staffed, with only three members present instead of the required six. Staff also failed to conduct proper hourly observations, with no adequate observation of Joshua between 3:05 pm and 5:15 pm when he was found unresponsive.
Investigation findings highlight systemic issues
The Trust’s internal investigation further revealed serious shortcomings, including:
- Lack of detailed risk assessments
- Absence of professional curiosity
- Inadequate psychological support due to a long-term shortage of staff
- Poor holistic psychosocial assessment of Joshua
- Risk management that failed to meet his needs
Confusion over restricted items was evident, with most staff believing plastic bags were not permitted. Despite discussions at a Trust patient safety meeting in October 2017 regarding plastic bags, no subsequent action was recorded.
Family response and call for improvements
Tees Law, representing Joshua’s family, stated that the inquest findings reflect concerns previously raised by Joshua’s father, Malkeet Sahota. These concerns were further exacerbated upon learning of other deaths at Wedgwood House in recent years.
“Joshua’s dad, Malk, 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. Seeing that the jury recognised Joshua as an intelligent, polite, and well-loved young man is heartening.”
Malkeet Sahota has expressed a strong desire for systemic improvements in mental health care. He welcomed the coroner’s decision to raise a Prevention of Future Deaths Report to the Minister for Mental Health and Patient Safety, particularly regarding the communication of restricted item policies to families and visitors.
“The fact that the Coroner has raised concerns on a national level about restricted items on mental health wards and the importance of communicating these issues with families shows just how vital inquests like Joshua’s are,” Tees Law concluded.
