Source · Prevention of Future Deaths

Janet Millar

Ref: 2016-0444 Date: 15 Dec 2016 Coroner: Nicholas Rheinberg Area: Cheshire Responses identified: 0 / 1 View PDF

A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking policy.

Date 15 Dec 2016
56-day deadline 9 Feb 2017
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking policy.
View full coroner's concerns
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.

Report sections

Investigation and inquest
On 5th June 2015 an investigation into the death of Janet Esme Millar was commenced. The investigation concluded at the end of the inquest on 1st December 2016. The conclusion of the inquest was that the deceased, whose medical cause of death was 1(a) hanging, had died by suicide.
Circumstances of the death
The deceased who suffered from schizophrenia had been admitted to the Rosewood Unit of your hospital for rehabilitation. Ultimately she was held subject to section 3 of the Mental Health Act. In common with the majority of those diagnosed with a mental illness, the deceased was addicted to nicotine through cigarette smoking. The inquest heard evidence to the effect that Bowmere Hospital had, prior to the admission of the deceased, adopted a non-smoking policy for patients and staff. The deceased showed no interest in breaking her addiction and quitting smoking although there was evidence to the effect that she had been offered nicotine replacement therapy. There was a suspicion that some members of the nursing staff, although readily enforcing the smoking ban, were not fully engaged in addressing the problem of nicotine addiction and that this revealed a possible training deficit.

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Report details

Reference
2016-0444
Date of report
15 December 2016
Coroner
Nicholas Rheinberg
Coroner area
Cheshire

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Feb 2017.

Sent to

Bowmere Hospital

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