Recurring concern

NHS smoke-free policy inadequately protects safety in mental health hospitals

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First reported 25 Jan 2018•Latest report 22 Nov 2024

Definition

What this concern includes

Includes deficiencies in the design, interpretation, implementation, guidance, review or dedicated operational controls of the NHS smoke-free policy where they directly concern safe management of smoking, nicotine treatment or smoking-related leave for mental health inpatients or detained patients.

Not included

Excludes generic failures to account for differing needs where no direct connection to the NHS smoke-free policy or smoking-related safety is established.
Excludes general mental-health risk assessment, observation, staffing or environmental deficiencies not specifically dedicated to safe operation of the NHS smoke-free policy.
Excludes ordinary smoking-cessation or public-health concerns that do not create a safety problem in mental health hospital care.
Excludes unrelated failures in other clinical guidance, discharge processes or information-sharing systems.

Reports: 2
Individual concerns: 5
Date range: 2018–2024
Stated actions: 4

Reports 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.

NHS England2

Department of Health and Social Care1

National Institute for Health and Care Excellence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

22 Nov2024
East Sussex
Concerns raised2
1. Inadequacy of national guidance on smoking and section 17 leave
2. Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Advance the Tobacco and Vapes Bill to expand smoke-free-place provisions, including potential outdoor spaces.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Conduct consultation on making hospital grounds smoke-free and consider whether designated smoking areas are appropriate.
  Stated by Department of Health and Social CareStated planned
Respondent positions 7
1. Position
  NICE and DHSC are responsible for responding to concerns about national smoking and Section 17 leave policy.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Contradictions in national policy concerning smoking cessation in acute mental-health inpatient care fall outside NICE’s remit.
  Stated by National Institute for Health and Care ExcellenceOutside remit
2. Position
  NHS England is considered best placed to address contradictions in national policy concerning smoking cessation in acute mental-health inpatient care.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
3. Position
  Existing legal and regulatory arrangements provide that Section 17 leave requires clinician authorisation and risk assessment and should not facilitate smoking breaks.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
4. Position
  NHS England is responsible for addressing concerns about national guidance and policy, while the NHS trust is addressing local issues.
  Stated by Department of Health and Social CareRedirects responsibility
5. Position
  There is no known published evidence that smoke-free policies increase mental health patients’ risk of self-harm or suicide.
  Stated by NHS EnglandDisputes the concern
6. Position
  Research indicates that smoke-free policies do not exacerbate mental health symptoms, and trusts have implemented them with few unintended consequences.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Nicolette Elizabeth McCARTHY · 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

Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.

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
Inadequacy of national guidance on smoking and section 17 leave
Wider context from the report
“1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide. 2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery. 3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health. 4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide. 5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life. 6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions. 7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave. ”
Source location
Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report
Page 2 · 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 of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke
Wider context from the report
“1) During the course of the inquest, I heard evidence from clinicians and staff at the Trust to the effect that the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide. 2) Although smoking cessation advice and treatment (e.g. gum, vapes etc.) are routinely offered to patients, the evidence was that many struggle to give up smoking on their admission to the ward, in part because the anxiety associated with stopping exacerbates their mental health symptoms. Staff also felt that forcing patients to stop smoking against their will (e.g. by prohibiting them from smoking while on leave) would have a negative effect on their sense of autonomy and wellbeing, which are important for recovery. 3) The Trust understand that they are bound by the Health Act 2006 and by NHS England policy not to permit or facilitate smoking on the ward or anywhere on the grounds of the hospital. This is taken seriously and is interpreted to mean that staff are prohibited from facilitating smoking, for example by granting leave for the purpose of smoking or by escorting patients to smoke outside on short periods of leave. Senior staff also believed that it would be contrary to NHS policy to permit smoking in a secure area, for example the enclosed ward garden. At the same time, it was acknowledged that patients would inevitably seek leave to smoke and that this could not be denied without a negative impact on their mental health. 4) The jury heard evidence that patients, like Mrs McCarthy, were routinely given 15-minute grounds leave for the purpose of smoking, a practice that is discouraged by the Trust. Clinical staff felt that the policy placed them in a difficult position, torn between the need to comply with the smoke free policy, while also supporting patient autonomy and keeping safe those patients who are at a higher risk of self-harm or suicide. 5) There is a further contradiction caused by the smoke free policy, in that patients are not permitted to smoke on the grounds, but are not supposed to leave the grounds during short periods of ‘grounds’ leave. The result is that patients would spend their 15-minute leave smoking by the side of the road on the edge of the ward grounds, which is a poorly supervised area, and staff would avoid asking them too closely where they were going and would avoid standing close to them, even when smoking themselves. This contributed to the circumstances that allowed Mrs McCarthy to slip away unnoticed and ultimately to take her own life. 6) I also heard evidence from senior staff that the national policy guidance intended to address smoking and s17 leave (e.g. the NICE guidance and CQC guidance) does not adequately resolve these contradictions. 7) I am concerned that the NHS smoke free policy, while clearly motivated by a genuine and pressing concern to protect life and promote health, may not be adequately tailored to reflect the safety requirements of mental health wards or the reality that some mental health patients will inevitably seek short periods of leave to smoke. Action may need to be taken at the national policy level to provide clearer guidance and/or review the law to reduce the risk of patients in mental health wards absconding while on unescorted grounds leave. ”
Source location
Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report
Page 2 · 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
Advance the Tobacco and Vapes Bill to expand smoke-free-place provisions, including potential outdoor spaces.

Verbatim wording from the response
“You may also be aware that the Department is currently taking action to tackle the harms of second-hand smoking through the Tobacco and Vapes Bill which is currently making its way through Parliament. Part of the Bill provides ministers with powers to expand the current smoke-free places provisions in the Health Act 2006 to more public places and workplaces, including outdoor spaces. In England, we have announced our intention to make outside hospital grounds smoke-free. This will be subject to a consultative process and as part of this we will consider whether designated areas for smoking are appropriate.”

Source location
Response from DHSC
Page 2 · response
Published 28 November 2024
Open published response
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
Conduct consultation on making hospital grounds smoke-free and consider whether designated smoking areas are appropriate.

Verbatim wording from the response
“You may also be aware that the Department is currently taking action to tackle the harms of second-hand smoking through the Tobacco and Vapes Bill which is currently making its way through Parliament. Part of the Bill provides ministers with powers to expand the current smoke-free places provisions in the Health Act 2006 to more public places and workplaces, including outdoor spaces. In England, we have announced our intention to make outside hospital grounds smoke-free. This will be subject to a consultative process and as part of this we will consider whether designated areas for smoking are appropriate.”

Source location
Response from DHSC
Page 2 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NICE and DHSC are responsible for responding to concerns about national smoking and Section 17 leave policy.

Verbatim wording from the response
“I note that you have also addressed your concerns to NICE and the DHSC, and it would be appropriate for these organisations to respond to the Coroner, as the responsible policy holders for the issues raised. Individual NHS Trusts are responsible for the local implementation of these policies and not the wider NHS England Estates Team.”

Source location
Response from NHS England
Page 3 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Contradictions in national policy concerning smoking cessation in acute mental-health inpatient care fall outside NICE’s remit.

Verbatim wording from the response
“Given that the matters of concern relate to contradictions in national policy, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and I note that your report has also been sent to them. The Care Quality Commission (CQC) may also be able to provide useful feedback to the points raised.”

Source location
Response from NICE
Page 1 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is considered best placed to address contradictions in national policy concerning smoking cessation in acute mental-health inpatient care.

Verbatim wording from the response
“Given that the matters of concern relate to contradictions in national policy, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and I note that your report has also been sent to them. The Care Quality Commission (CQC) may also be able to provide useful feedback to the points raised.”

Source location
Response from NICE
Page 1 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing legal and regulatory arrangements provide that Section 17 leave requires clinician authorisation and risk assessment and should not facilitate smoking breaks.

Verbatim wording from the response
“Turning to your concerns regarding a lack of clarity around using Section 17 of the Mental Health Act 1983 to allow inpatients a short leave of absence in order to take a smoking break. Under Section 17 of the Act, a leave of absence can only be authorised by the patient’s responsible clinician and would require a risk assessment to be undertaken. The Care Quality Commission’s guidance: Smokefree policies in mental health inpatient services³ makes it clear that Section 17 should not be used to facilitate smoking breaks.”

Source location
Response from DHSC
Page 2 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is responsible for addressing concerns about national guidance and policy, while the NHS trust is addressing local issues.

Verbatim wording from the response
“I understand that, in its response to your report, NHS England will address your concerns around national guidance and policy and is also engaging with the Sussex Partnership NHS Foundation Trust to provide information about the local issues you have raised.”

Source location
Response from DHSC
Page 2 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
There is no known published evidence that smoke-free policies increase mental health patients’ risk of self-harm or suicide.

Verbatim wording from the response
“Your report states that NHS England’s smoke free policy places mental health inpatients at an increased risk of self-harm and suicide. Currently, there is no known published evidence that smoke free policies place patients at an increased risk of self-harm or suicide.²”

Source location
Response from NHS England
Page 2 · response
Published 28 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Research indicates that smoke-free policies do not exacerbate mental health symptoms, and trusts have implemented them with few unintended consequences.

Verbatim wording from the response
“I understand the concerns raised in your report about whether a smoke-free policy covering hospital grounds may place mental health inpatients at an increased risk from self-harm and suicide. However, research carried out on smoking bans in psychiatric inpatient settings⁴ indicates that smoking cessation does not exacerbate mental health symptoms. I am also aware of a number of mental health trusts that have implemented smoke-free policies successfully, resulting in high rates of compliance and few unintended consequences.”

Source location
Response from DHSC
Page 2 · response
Published 28 November 2024
Open published response
25 Jan2018
Black Country
Concerns raised3
1. Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication
2. Failure of guidance to account for differing safety needs across hospital types
3. Lack of a tool to depart from smoke-free hospital guidance where necessary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Raise the complexity of smoking and section 17 leave with the Department of Health and Social Care through the government-led Mental Health Act review response.
  Stated by NHS EnglandStated planned
2. Action
  Suggest that smoking and section 17 leave be considered in future revisions to the Mental Health Act Code of Practice.
  Stated by NHS EnglandStated planned
AI-generated summary

David Squire · 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

David Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.

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
Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication
Wider context from the report
“1. This guidance does not permit the proper use of Section 17 leave. The Priory is a smoke free hospital in accordance with NHS England guidance and cannot have a smoking area on the hospital grounds. To allow patients to smoke, Section 17 leave is utilised outside of The Priory’s grounds. Section 17 leave should be used for many purposes, including patent observation and interaction and to assess whether they are a risk of absconding. Given that purpose, the process of leave is staged. Patients start with escorted leave within the grounds, then unescorted, then escorted leave off grounds and then unescorted. Patients, who refuse nicotine replacement medication, and continue to smoke, must start the staged leave at escorted “off grounds.” This is so The Priory can comply with the NHS England guidance. Smoking patients therefore start leave at “off grounds” without the staged process and level of observation that non-smoking patients would be offered. ”
Source location
David Squire · Prevention of Future Deaths report
Page 2 · 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 of guidance to account for differing safety needs across hospital types
Wider context from the report
“2. The guidance fails to account for the differing needs regarding the different type of hospital that the policy spans. The application of the guidance to a standard NHS hospital creates far less of a risk than it does to a mental health hospital where it is accepted there is a frequency of patients who are at risk of absconding, self-harm and harm to others. The guidance leaves mental health hospitals, when detained patients smoke and refuse nicotine replacement therapy, to take detained patients off grounds in undesirable circumstances. The guidance, as it stands, with no tool to depart from the guidance, where necessary, leaves a significant risk. ”
Source location
David Squire · Prevention of Future Deaths report
Page 2 · 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 a tool to depart from smoke-free hospital guidance where necessary
Wider context from the report
“2. The guidance fails to account for the differing needs regarding the different type of hospital that the policy spans. The application of the guidance to a standard NHS hospital creates far less of a risk than it does to a mental health hospital where it is accepted there is a frequency of patients who are at risk of absconding, self-harm and harm to others. The guidance leaves mental health hospitals, when detained patients smoke and refuse nicotine replacement therapy, to take detained patients off grounds in undesirable circumstances. The guidance, as it stands, with no tool to depart from the guidance, where necessary, leaves a significant risk. ”
Source location
David Squire · Prevention of Future Deaths report
Page 2 · 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
Raise the complexity of smoking and section 17 leave with the Department of Health and Social Care through the government-led Mental Health Act review response.

Verbatim wording from the response
“In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.”

Source location
2019-0062-Response-by-NHS-England
Page 2 · response
Published 26 May 2019
Open published response
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
Suggest that smoking and section 17 leave be considered in future revisions to the Mental Health Act Code of Practice.

Verbatim wording from the response
“In response to your request for further consideration I can confirm NHS England will raise the complexity of this issue with the Department of Health & Social Care as part of its contributions to the government-led response to the Independent Review of the Mental Health Act that reported to the Prime Minister in December 2018. The government has signalled its intention to legislate in response to the review, and NHS England will suggest that the issue of smoking and use of section 17 leave should also be considered as part of future revisions to the Code of Practice.”

Source location
2019-0062-Response-by-NHS-England
Page 2 · response
Published 26 May 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Inadequacy of national guidance on smoking and section 17 leave

Failure of the NHS smoke-free policy to reflect the safety requirements of mental health wards and patients seeking leave to smoke

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7

Concerns raised3

Failure of smoke-free hospital guidance to permit staged Section 17 leave for smoking patients refusing nicotine replacement medication

Failure of guidance to account for differing safety needs across hospital types

Lack of a tool to depart from smoke-free hospital guidance where necessary

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 2

Respondent positions 7

Actions described in response 2