Josh Sahota inquest concludes with coroner calling for more communication about restricted items at mental health units
A jury has decided that the death of 25 year-old man from Kennett who was found dead in a Bury St Edmunds mental health unit was due to asphyxia and psychosis.
The jury at Suffolk Coroner's Court returned the unanimous decision on Joshua Sahota.
The inquest had heard in previous days that Mr Sahota was found in his room by staff at the Wedgwood mental health unit on September 9, 2019, with a plastic bag around his head.
The jury said contributing factors to his death included insufficient staffing on the day, insufficient observations and one to ones with Mr Sahota, inadequate formal documentation such as risk assessments and a crisis plan as well as no psychologist being in place.
The jury also said there were inconsistencies in the understanding of the restricted items policy at the unit by staff and visitors
Nigel Parsley, senior coroner, said Norfolk and Suffolk Foundation Trust had already taken steps and changes in light of the death including a completely new care group structure to bring greater leadership in the trust and a modern matron had been appointed to the unit to oversee nursing care and treatment regimes. Meanwhile, a psychiatrist could now consult with patients without a nurse being present increasing the availability of them, a new observation policy was in place and there had been a review into the access of restricted items on the ward.
The inquest also heard that in October 2019, the Care Quality Commission said that banned items should include all plastic bags.
Mr Parsley did say however that he would raise a Regulation 28 report - prevention of future death order - in relation to the communication of the restricted item regime to family and friends of patients before they visit a ward, particularly on their first visit.
The coroner said he would raise this concern not just with the trust but also with the Minister for Patient Safety, Suicide Prevention and Mental Health.