Inquest exposes continuing and dangerous risk of restricted items on mental health wards

Written on 21st September 2021 | 5 minute read

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 the use of a bed sheet around his neck.

The inquest heard that Joshua was a quiet young man who kept himself to himself and staff only got to know him superficially. It appears they were, therefore, unable to make an adequate assessment of the risk that he posed to himself while under the unit’s care despite him being a continued high risk of suicide throughout his admission. Joshua had previously deliberately driven a car off a bridge onto the A14 near Newmarket.

The jury was unable to determine Joshua’s state of mind at the time of his death but concluded that contributing factors that led to his death were insufficient staffing, insufficient observations and 1-to-1s, inadequate documentation, no psychologist available and unclear restricted items policy.

The coroner raised a ‘Prevention of Future Deaths Report’ not only directly with the Trust but, unusually – and evidence of the seriousness of the restricted items issue on a national level – also with the Minister for Mental Health and Patient Safety.

Joshua’s admission to Wedgwood House

Serious concern over Joshua’s state of mind had led to his admission to Wedgwood House, located at the West Suffolk Hospital site in Bury St Edmunds, although the unit is operated separately by regional mental health service provider Norfolk and Suffolk NHS Foundation Trust.

The Hospital Trust was previously rated as inadequate and placed under special measures in 2017 following a review by the Care Quality Commission (CQC). Since November 2018, the Trust has had 21 Mental Health Act monitoring visits, resulting in 96 actions that the Trust was required to address.

At the inquest, it was revealed that the NHS Trust had no definitive local policy regarding the allowing of plastic bags, belts, shoe laces, etc., within the mental health ward, and it appears that staff members each had differing practices regarding the monitoring and removal of such items.

In addition, the inquest heard evidence that there was an inadequate care plan in place at the unit for Joshua; the busy ward was short-staffed on the day Joshua died with three members of staff instead of six and there was an inconsistent approach to hourly observations with no adequate observation of Joshua between 3.05 pm and 5.15 pm when he was found unresponsive.

Furthermore, the findings of the Trust’s own investigation included that the review team’s risk assessment was lacking in detail; there was an absence of professional curiosity, likely due to a long-term lack of psychology staff to assist and support the team; a series of Care and Service delivery issues, such as the lack of a holistic psychosocial assessment of Joshua, and that the risk management was not proportionate to the needs of Joshua.

There was found to be evident confusion regarding what items were banned from wards in this area of the Trust, with most staff reporting as far as they were concerned plastic bags were not permitted on the wards. The matter of plastic bags had been discussed at a Trust patient safety meeting in October 2017, with no action recorded against the discussion.

“The inquest findings largely reflect concerns previously expressed by Joshua’s father, Malkeet Sahota, about the standard of care and treatment that his son received whilst a patient at Wedgwood House,” explains Tees Law, acting for the family. “These concerns have only been exacerbated by the family’s learning of earlier Wedgwood House deaths during the last several 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 that Joshua was an intelligent, polite and well-loved young man is heartening. Their conclusion substantiates the family’s concerns that multiple serious failings by the Trust led to Joshua’s tragic death in September 2019.

“Malk, particularly, is keen to see real improvements to the provision of mental health care in England and the Coroner’s decision to raise a Prevention of Future Deaths Report not only to the trust but to the Minister for Mental Health and Patient Safety, on the issue of communication of the restricted item regime to family and friends of patients before they visit the ward, is an important step in the right direction.

“The fact that the Coroner has raised concerns on a national level about restricted items on mental health wards and particularly communicating these issues with family and friends to ensure they fully appreciate the seriousness that such items can have shows just how important inquests such as Josh’s are, not only to the family but to all users of mental health services.”