The parents of a 25-year-old man who died at a mental health unit have called for a national blanket ban on plastic bags on wards after receiving an "unsatisfactory" response from a government minister.
IT programmer Joshua Sahota, from Newmarket, died as a result of asphyxia and psychosis in Bury St Edmunds, on September 9, 2019.
Mr Sahota was taken to the Wedgwood Unit based on the West Suffolk Hospital site - which is run separately by the Norfolk and Suffolk NHS Foundation Trust (NSFT) - four weeks before his death.
An inquest jury at Suffolk Coroner's Court concluded that insufficient staffing levels contributed to his death as well as the absence of a documented care plan, and insufficient observations and one-to-one processes.
The inquest also found that a plastic bag which contributed to his death was on a restricted items list, but the policy was "unclear" and there were "inconsistencies" in staff and visitor understanding.
Following the inquest, Nigel Parsley, senior coroner for Suffolk, wrote to the Department for Health and Social Care (DHSC) and NSFT with his concerns.
In her response to Mr Parsley, Gillian Keegan MP, minister for care and mental health, wrote that the Care Quality Commission (CQC) considered that Mr Sahota’s death was "an incident of avoidable harm", but the watchdog concluded that there were no grounds for a criminal prosecution.
She added the CQC has published a guide 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.
However, trusts are still given the option to decide for themselves what items are placed on the prohibited and restricted items list and are able to risk assess individuals to determine whether it is suitable for them to have access to a particular restricted item.
NSFT said plastic bags were banned from all wards following Mr Sahota's death.
Mr Sahota's father, Malk, previously called for the seriousness of the coroner's concerns to be acknowledged and real and immediate action to be taken.
Asked if he was satisfied with the minister's response, he said: "Not really because I just feel like they haven't done enough. They've not really gone deep enough to understand what mental health's about.
"You need to have a list of contraband, but it needs to be standardised nationally so there is a guideline and then you can follow that for good practice. But when you start having wishy washy do whatever you like, it dilutes the message.
"The coroner bent over backwards to try and get this in. A major coroner saying: 'let's do this, let's make it national' and then the minister ignores it and just washes it over - it's not really a satisfactory way of progressing health and safety."
Lynette Fordham, Mr Sahota's mother, said: "I definitely feel that it should be standardised across the whole country, not just the trusts making their own decisions on what is on the restricted items list.
"Especially when a lot of people in those units will be suicidal, they really do need to have clear national guidelines.
"The legacy for Joshua is preventing other young men and women or anybody doing the same thing that he did."
Craig Knightley, solicitor at Tees Law, who represented the family, said: “While it is positive that there are signs of some improvement particularly at the trust, it is vital that progress continues to be made to ensure that no family ever has to go through the tragedy Joshua’s family have had to endure.
"The actions taken by Norfolk and Suffolk NHS Foundation Trust must be replicated across the UK to ensure the widespread removal of plastic bags from acute mental health wards, to improve communication with family and carers, and to protect those who are most vulnerable in our society.
“Urgent, further, consideration must be undertaken by the government in respect of a blanket ban of all plastic bags on all mental health wards, as deaths continue to occur year on year, despite nationwide safety alerts and policy reviews.”
Stuart Richardson, chief executive at NSFT, said: “Joshua’s death was a tragic accident and we’re deeply sorry for the pain caused to his family.
“We are doing all that we can to prevent such a tragedy being repeated."
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