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Patient Safety Learning added a new entry to the News blog
A coroner has raised concerns about how a family was allowed to bring a restricted item that contributed to a man's death into a mental health unit.
Joshua Sahota, 25, died as a result of asphyxia and psychosis in Bury St Edmunds, Suffolk, on 9 September 2019.
Suffolk coroner Nigel Parsley said Mr Sahota's relatives were not told the item they brought in when visiting was on a restricted list.
The NHS trust which runs the unit said it had improved its internal processes.
Mr Sahota, from Kennett in Cambridgeshire, was taken to the Wedgewood Unit on the West Suffolk Hospital site three weeks before his death as his mental health had declined.
Insufficient staffing levels contributed to his death, an inquest jury at Suffolk Coroner's Court concluded.
Other factors included insufficient observations and one-to-one processes, no clear and concise risk assessments, being slow to develop a care plan and the absence of a documented crisis plan.
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Source: BBC News, 21 September 2021