Recurring concern

Unreliable recognition and management of nicotine withdrawal

First to latest report 20 Dec 2013 — 15 Dec 2016

Reports that mention this concern: 2
Times this concern has been raised: 5
Stated actions linked to this concern: 1

What this concern includes

Includes failures in recognising, screening for, assessing, communicating about or managing nicotine or tobacco withdrawal, including staff training, responsibility allocation and support during prison reception, hospital admission or implementation of a non-smoking policy.

What is not included

Excludes general smoking-cessation provision or nicotine-replacement access where nicotine withdrawal recognition or management is not the identified unsafe condition.
Excludes alcohol, opioid or other substance-withdrawal processes unless nicotine or tobacco withdrawal is also the material concern.
Excludes generic staff-training, staffing or communication deficiencies that are not specifically tied to nicotine-withdrawal recognition or management.
Excludes broader smoke-free-policy implementation failures where nicotine withdrawal is not the deficient control.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Belmarsh Prison1

Cheshire and Wirral Partnership NHS Foundation Trust1

HM Prison and Probation Service1

NHS England1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

15 Dec2016
Cheshire
Concerns raised1
1. Training deficit in supporting patients withdrawing from nicotine
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Janet Esme Millar · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Janet Esme Millar, who had schizophrenia and was detained under section 3 of the Mental Health Act, was admitted to the Rosewood Unit for rehabilitation and later died by suicide, with the medical cause of death recorded as hanging. The report raised concern that some nursing staff may not have been fully engaged in addressing nicotine addiction and that this indicated a possible training deficit alongside the hospital’s non-smoking policy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Training deficit in supporting patients withdrawing from nicotine
Wider context from the report
“Most of those admitted to your hospital are addicted to nicotine. Some are suicidal. You have recognised that hand in hand with a non-smoking policy it is necessary to break the cycle of addiction and support those who are withdrawing. It would be a concern if there is a training deficit as identified in the previous section and this would need to be addressed. ”
Source location
Janet Esme Millar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
20 Dec2013
Inner South London
Concerns raised4
1. Lack of health care staff training to manage tobacco withdrawal
2. Unclear responsibility for tobacco-withdrawal screening and management
3. Lack of health care staff training to conduct tobacco-withdrawal screening
1. Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

HM Prison and Probation Service
Stated actions 1
1. HM Prison and Probation Service
  Develop a care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.
AI-generated summary

Adrian Johnson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of health care staff training to manage tobacco withdrawal
Wider context from the report
“(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”
Source location
Adrian Johnson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unclear responsibility for tobacco-withdrawal screening and management
Wider context from the report
“(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”
Source location
Adrian Johnson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of health care staff training to conduct tobacco-withdrawal screening
Wider context from the report
“(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”
Source location
Adrian Johnson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening
Wider context from the report
“(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”
Source location
Adrian Johnson · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.

Verbatim wording from the response
“NOMS accepts that despite the above range of screening during the reception process, further consideration needs to be given to identifying prisoners for whom tobacco withdrawal may give rise to an increase in suicidal feelings or self-harm, and to develop the support given to prisoners who do not have access to tobacco, or to the amount they would normally rely on. NOMS is currently working with healthcare partners to develop a care pathway, that includes an appropriate level of screening, to ensure that when tobacco is not available, or it is available but in more limited supply than the level they are used to (because they have limited funds/access to prison shop), that the relevant healthcare provider ensures that appropriate support, including Nicotine Replacement Therapy is available.”

Source location
2013-0364-Response-by-NOMS
Page 2 · response
Published 20 December 2013
Open published response