David Squire · Prevention of Future Deaths report

1. On 30/07/2018 I commenced an investigation into the death of David Squire. The investigation concluded at the end of the inquest on the 23/01/19.

2. The conclusion of the inquest was misadventure.

3. The medical cause of death was

1a) Hanging by Ligature

1. On the 25/07/18 David Squire took his own life by hanging himself from a low bridge in Fibbersley Nature Reserve in Willenhall. David Squire was a detained patient having been detained under Section 2 of the Mental Health Act at a care home nearby called The Priory at Lakeside View Care Home.

2. During the course of the inquest evidence was heard as to David Squire’s admission to The Priory on the 22/7/18 under Section 2 of the Mental Health Act. This was because he had suicidal thoughts and thoughts of harming others. The Priory was, and still is, a non-smoking hospital in accordance with guidelines set down by NHS England. This states that all hospitals are to be non-smoking. Non-smoking meaning that no smoking is permitted on the premises or grounds of any hospital. The smoking area at The Priory was therefore located outside of the hospital grounds.

3. The Priory offers nicotine replacement to patients that smoke. For patients who refuse and want to smoke a cigarette, permission has to be obtained for escorted “off grounds” leave. This is called Section 17 leave.

4. On Tuesday 24/7/2018 David Squire was permitted to have escorted leave off of the grounds of the Priory Lakeside view, for a cigarette. When he had finished his cigarette he refused to come back to The Priory Lakeside View and left. ON the 25/7/18 he was found deceased at in Fibbersley Nature Reserve in Willenhall.

Evidence emerged during the inquest which pointed towards two areas of concerns regarding the NHS England Guidance regarding smoke-free hospitals:

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.

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.