Joshua Sahota died as a result of asphyxia and psychosis while a patient in Northgate Ward at Wedgewood House, operated and staffed by Norfolk and Suffolk NHS Foundation Trust.
In his report, the Coroner raised patient safety concerns regarding how the trust communicates to relatives which items are restricted and not allowed to be brought into the ward. He raised concerns that family and friends of current inpatients may still inadvertently take a restricted item onto the ward unless changes are put in place.
Joshua Sahota had been admitted to Southgate Ward at Wedgewood House on 9 August 2019 following a stay as an inpatient at Addenbrookes Hospital, where he had been seen by a psychiatrist and deemed to be at a continuing high risk of self-harm.
His family were asked to take fresh clothes to the Southgate Ward, which they did so in a plastic carrier bag. It had not been communicated to them that this was a ‘restricted item’ on the ward. Joshua was subsequently transferred to Northgate Ward, also within Wedgewood House, on the 15 August 2019. On the 9 September 2019, Josh was found in his room, having died as a result of asphyxia, by deliberately placing a plastic bag over his head and use of a bed sheet around his neck.
The Coroner in his investigation raised concerns regarding the communication of what are restricted and contraband items to the family and friends of patients before they visit the mental health ward. It was noted that while there are signs in the ward detailing items that are contraband, there are also restricted items that can differ from patient to patient, depending on their risk assessment.
He raised specific concerns that:
- No clear system or procedure was in place for family and friends to be notified of any particular items that have been deemed restricted items for their loved one to have in their possession.
- In the absence of this, current inpatients may still inadvertently take a restricted item onto the ward.
The Coroner’s report was sent to the Minister for Patient Safety, Suicide Prevention and Mental Health and the Chief Executive of Norfolk and Suffolk NHS Foundation Trust.