Inadequate staffing contributed to man's death in mental health unit, inquest rules

Inadequate staffing and confusion about ‘restricted items’, such as plastic bags, led to a 25-year-old computer programmer taking his own life in a mental health trust, an inquest ruled.

The inquest jury found that Joshua Sahota, 25, from Kennett, Cambridgeshire, died on 9 September 2019 from psychosis and asphyxia, using two unrestricted items, in Wedgwood House mental health unit, Bury St Edmunds, Suffolk, which is operated separately by regional mental health service provider, Norfolk and Suffolk NHS Foundation Trust.

The inquest heard that the NHS Trust had no definitive policy about allowing restricted items within the mental health ward with members of staff applying differing practices in relation to monitoring and removing them.

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

The jury heard that there was an inadequate care plan for him; only three, instead of six members of staff on duty on a busy ward; there was inconsistency about hourly observations and his was missed between 3.05pm and 5.15pm when he was found unresponsive.

The Trust’s own investigation found that the review team’s risk assessment lacked detail. It said Mr Sahota’s risk management did not meet his needs and that there was a series of care and service delivery issues, including the lack of a holistic psychosocial assessment.

There was found to be confusion about what items were banned from wards in the unit, with most staff reporting that items such as plastic bags were not permitted on the wards. The matter of restricted items was discussed at a trust patient safety meeting in October 2017 but no action recorded against the discussion.

The hospital trust had been rated ‘inadequate’ and placed in special measures in 2017 following a review by health and care regulator, the Care Quality Commission (CQC).

The Trust has had 21 Mental Health Act monitoring visits since November 2018 and asked to address 96 elements of its care.

Suffolk senior coroner, Nigel Parsley, said he would raise 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 Sahota’s father, Malk Sahota, said he was "so angry and frustrated" at the Norfolk and Suffolk NHS Foundation Trust (NSFT).

He said: “They failed him completely. They ignored him while he was there, nobody talked to him and there was no psychologist there to talk to him."

NSFT chief executive, Stuart Richardson, said: "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."