Source · Prevention of Future Deaths

Joshua Sahota

Ref: 2021-0301 Date: 9 Sep 2021 Coroner: Nigel Parsley Area: Suffolk Responses identified: 2 / 2 View PDF

Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.

Date 9 Sep 2021

56-day deadline 4 Nov 2021

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.

View full coroner's concerns

the MATTERS OF CONCERN;-. – relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward. This would be particularly important for a family or friends first visit to the ward. The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances. This makes it clear to all visitors what cannot be taken onto the ward in any circumstances. However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not. From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item. We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room. From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance. Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room. During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession. There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case. I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one. It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends.

Responses

2 respondents

Hellesdon Hospital NHS / Health Body

30 Sep 2021 PDF

Action Taken

Hellesdon Hospital has implemented a complete ban on plastic bags, improved communication to families and carers, and put safeguards in place to disrupt the passage of restricted items. (AI summary)

View full response

Dear Mr Parsley Regulation 28/29 prevention of future deaths notice received from Suffolk Coroner in relation to the death of Joshua Sahota I write in response to your letter dated 9 September 2021 raising your concerns in respect of the tragic death of Joshua whilst an inpatient at the Wedgwood Unit in Suffolk. The concerns relate specifically to the information given to visitors to the wards including. family and carers in respect of "restricted items", locally risk assessed, and/or fully "banned" items. As you are aware plastic bags were a· restricted item on our wards historically. To this end regular messaging and refreshing of the internal alert system featured this item, at that time the ward was undertaking individual risk assessments regarding the item. However, following the inquest evidence being submitted there remained the concern that family, and other visitors, were not aware of this "restriction" at that time, and that assurance was needed i.e. that plastic bags being a "banned' item is communicated effectively to all visitors and service users now. This item is a completely "banned" item across all inpatient units save our rehabilitation unit Improvements have b.een made to our external messaging to families and carers on this subject plus a number of safeguards have been put in place to disrupt the passage of restricted items includihg plastic bags. For example on entering the main Wedgewood reception visitors are asked to show what items they have brought to the unit, if these are within or contain a plastic bag a paper one will be given as a replacement. Likewise for any service user going out on leave, on return they will be given an alternative type of bag either paper or canvas. When advancing to the ward reception there are posters and a "sandwich board" which highlight various pieces of information including restrictions on items coming in to the ward namely plastic bags. Letters for both service users and carers have been updated to reflect the importance of not bringing restricted items on to wards and the rationale for this. This action was overseen by our People Participation Lead in West Suffolk and I attach copies for your information. I would also like to assure you that the necessity to remove all plastic bag type items including tape and plastic wadding from mail forms part of the local induction for both substantive and agency staff. Equally discussions about ward safety including the risk of items such as bags coming on to the ward is discussed at the various safety huddles every day; all staff are included in safety huddles, including our housekeeping colleagues. All service users returning from leave are asked to remove any type of plastic carrier or packaging from their person. Where thought necessary to safeguard the individual and other service users this may entail a search of the person and/or their bedroom area dependent on an individual risk assessment.

Working together for Trust HQs: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE Endeavour House, 8 Russell Rd, Ipswich IP1 2BX better mental health

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I hope that this information reassures you of our commitment to maintaing the safety of our seNice users and ensuring that families are not unknowingly increasirig ri,sk on our wards, This was a terrible tragic incident which resulted in the loss of a young man who had his life ahead of him, I can personally assure you that we as an organisation and as individual health care professionals do not want such a loss to occur ever again, hence we are doing all that we can to prevent such a tragedy being repeated,

Department of Health Social Care Central Government

17 Dec 2021 PDF

Noted

The Department of Health and Social Care acknowledges the concerns, mentions actions taken by the Norfolk and Suffolk NHS Foundation Trust, points to a safety alert published in 2011, and outlines progress in reducing suicides. (AI summary)

View full response

Dear Mr Parsley,

Thank you for your letter of 9 September 2021 about the death of Joshua Sahota. I am replying as Minister with responsibility for Mental Health and I am grateful for the additional time in which to do so.

Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr Sahota’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

Every suicide is a tragedy and learning lessons where things have gone wrong is essential to ensuring that the NHS provides safe, high quality care.

I am advised by the Care Quality Commission (the CQC), the independent regulator for quality in health and social care services, that it has undertaken regulatory activity in relation to Mr Sahota’s death, seeking assurance from the Norfolk and Suffolk NHS Foundation Trust of the actions it has taken following Mr Sahota’s death, and to address any ongoing risk to patients.

I understand that the Norfolk and Suffolk NHS Foundation Trust has explained in its response to your report that as a result of the internal investigation following from Mr Sahota’s death, the Trust has taken a number of actions to reduce the risk of a similar incident occurring. This includes a complete ban on plastic bags on acute mental health wards across the Trust, in addition to a number of improvements, including improved external communications to family and carers, together with a number of safeguards to disrupt the passage of restricted items.

The CQC considers that Mr Sahota’s death was an incident of avoidable harm, and, while the CQC has concluded that there are not grounds for a criminal prosecution, the CQC has identified that there was a breach of the regulations (specifically, Regulation 12 – safe care and treatment1). Further inspections of the Trust, which remains in special measures, have taken place and I am assured that the CQC will continue to monitor the Trust closely.

1 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (legislation.gov.uk)

In relation to restricted or prohibited items on acute mental health wards, you may wish to note that the CQC has published a guide to CQC inspectors2 on the use of ‘blanket restrictions’, which lists the items that are likely to be prohibited or restricted on mental health wards, and this includes plastic bags. The guide also describes the principles of risk assessment and personalised care that should be applied to restricted items. Local providers of care should ensure that there is a system in place to ensure that blanket restrictions are reviewed within a regular timeframe, with an overall aim of the reduction of restrictive practices.

On wards where items are restricted or prohibited, there should be auditable standards for how items are identified and what risk assessment is required; how adherence will be monitored and the policy reviewed; and, what information about the restrictions and the reasons for them is provided to patients and visitors.

In relation to plastic bags specifically, a safety alert was published in 20113 that highlighted the risks and recommended that providers of services review their policies relating to plastic bags. Mental health services are expected to be aware of the risks and to take the appropriate mitigation.

More generally, I would like to outline the progress we are making in reducing the number of suicides, which, in mental health inpatient settings, have reduced by more than half over the past decade. However, we recognise that the number remains too high. That is why, in 2018, we announced a Zero Suicide ambition, which has led to every mental health trust having a zero suicide policy (or ‘suicide safety plan’) in place.

This ambition is supported by a dedicated Mental Health Safety Improvement Programme which has a focus on reducing suicide and self-harm in inpatient mental health services, the healthcare workforce and non-mental health acute settings.

Both the Mental Health Safety Improvement Programme and regional suicide prevention leads will share learning on effective approaches to suicide prevention for people in contact with services and support ongoing implementation of the zero suicide plans. In light of the COVID-19 pandemic, NHS England and NHS Improvement will also be supporting mental health trusts to refresh and expand their zero suicide plans to include community settings during 2021 to 2022.

I hope this response is helpful.

GILLIAN KEEGAN

2 20191125_900767_briefguide-blanket_restrictions_mental_health_wards_v3.pdf (cqc.org.uk)

3https://webarchive.nationalarchives.gov.uk/ukgwa/20121107183145/http:/www.nrls.npsa.nhs.uk/resources/c linical-specialty/mental-health/?entryid45=130187

Report sections

Investigation and inquest

On 10th September 2019 I commenced an investigation into the tragic death of Joshua SAHOTA The investigation concluded at the end of the inquest on 8th September 2021. The jury conclusion of the inquest was that:- The jury recognise that Josh was an intelligent, polite, reserved well-loved and supported young man by his family and friends. Joshua Sahota died as a result of Asphyxia, by deliberately placing a plastic bag over his head and use of a bed sheet around his neck. We the Jury were unable to determine Josh’s state of mind at the time of his death. The below contributing factors led to Josh’s death.
• Insufficient staffing
• Insufficient Observations and 1 to 1’s
• Inadequate formal documentation
• No Psychologist available.
• Unclear restricted items policy. The medical cause of death was confirmed as: 1a Asphyxia Psychosis

Circumstances of the death

Joshua was a 25-year-old man who on the 2nd August 2019 intentionally drove his car off a bridge on the A11 landing on the A14 dual-carriageway beneath. This incident caused Joshua chest and pelvis injuries and as a result he was admitted to the Addenbrookes Hospital in Cambridge on the same day. Whilst Joshua had been an inpatient at Addenbrookes he had been seen by a psychiatrist and deemed to be at a continuing high risk of self-harm. As such, when Joshua was deemed medically fit, his discharge was directly to a psychiatric bed on Southgate Ward, Wedgewood House, Bury St Edmunds, in Suffolk. Joshua’s admission took place on the 9th August 2019 as an informal patient. As Joshua was admitted directly from Addenbrookes he was in a hospital gown only, as his clothes had been cut from him when he arrived at Addenbrookes hospital from the scene of the road collision. Joshua’s family were asked to take fresh clothes to Southgate ward, which they did in a plastic carrier bag. The bag was emptied by a member of staff, the contents were searched, re-packed and then taken to Josh’s room. At this time plastic bags were a ‘restricted item’ on the ward, but Joshua’s family had not been told this. On the 15 August 2019 Joshua was transferred to Northgate Ward, another ward within Wedgewood House. On the 9th September 2019 at 17:07 Joshua was found in his room with bed sheet around his neck and the plastic carrier bag over his head. CPR commenced by staff based on the ward and they were subsequently joined by paramedics. Despite resuscitation attempts recognition of life extinct was timed at 17:45. At the time of his death Joshua was on hourly observations on the ward.

Action should be taken

In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th November 2021 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;-
1. Mr Joshua Sahota’s next of kin. I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Nigel PARSLEY Senior Coroner for Suffolk Dated: 09/09/2021

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Report details

Reference: 2021-0301
Date of report: 9 September 2021
Coroner: Nigel Parsley
Coroner area: Suffolk

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Nov 2021.

Sent to

Department of Health and Social Care

Hellesdon Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.