Joshua SAHOTA · Prevention of Future Deaths report

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

2 Psychosis

Joshua was a 25-year-old man who on the 2nd August 2019 intentionally drove his car off a bridge 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.

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.