A coroner has called on a Suffolk mental health unit to communicate more with patients' families and friends following the death of a man from Newmarket.
Joshua Sahota, 25, died after being admitted to Wedgwood House in Bury St Edmunds in 2019.
He had been admitted to the unit, run by the Norfolk and Suffolk NHS Foundation Trust (NSFT), following an incident where he drove off a bridge onto the A14.
Whilst at Wedgewood House, Mr Sahota's family brought him some clothes in a plastic bag.
Unbeknownst to the family, plastic bags were a prohibited item and despite checks by staff it still made its way onto the ward.
Mr Sahota later used a plastic bag to end his life. An inquest into his death confirmed he had died from asphyxia.
A prevention of future deaths report sent to NSFT and the Government, by senior coroner for Suffolk, Nigel Parsley said that there had been "no effective communication" between the family and ward about items that could not be brought to Mr Sahota.
He called for the trust to take action.
"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," said Mr Parsley in his report.
NSFT had previously said that there were signs on the ward warning visitors of what they could not bring in. Despite this, some patients were allowed restricted items depending on their assessment by staff.
Mr Parsley said that if Mr Sahota's family had known the rules they would have never brought a restricted item to the ward.
Stuart Richardson, chief executive at NSFT said: “I am deeply sorry for Joshua’s death and I am keen to support his family in any way I can.
"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."
A full internal investigation was carried out after Mr Sahota's death.
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules here