East Sussex Family Supported By Medical Negligence Lawyers Backs Coroner’s Call For Action

Mental health patients are being put at unnecessary increased risk of suicide because of NHS policy banning smoking in hospital grounds, a concerned coroner’s report has found. 

Mum-of-five Nicolette McCarthy was allowed 15-minutes unescorted ‘hospital grounds’ leave at the Woodlands Centre in St Leonards-on-Sea, East Sussex, where she had been detained under the Mental Health Act. The leave was granted for the purpose of her going to smoke, an inquest heard.

However, the 46-year-old was also allowed to leave with her phone and money. She left the grounds and almost immediately called a taxi to take her to Hastings train station. She made the near 20-mile journey to Beachy Head. Shortly afterwards, Nicolette’s body was found near the beauty spot.

Nicolette's family ask medical negligence lawyers to secure answers

After Nicolette’s family instructed specialist medical negligence lawyers at Irwin Mitchell to secure answers, an inquest found Nicolette, of Uckfield, East Sussex, died following a “series of failures” in her care. 

While Sussex Partnership NHS Foundation Trust, which runs the hospital, upheld the NHS smoke free policy, meaning Nicolette should have been banned from smoking in the grounds, patients “were routinely given 15-minute grounds leave for the purpose of smoking”, the coroner’s report said.

As a result of “a further contradiction caused by the smoke free policy”, patients would spend their leave smoking by the side of the road on the edge of ward grounds. This was a poorly supervised area and staff would avoid asking patients where they were going and avoid standing close to them, the report said. 

This contributed to the circumstances that allowed Nicolette “to slip away unnoticed and ultimately to take her own life,” the coroner’s report added. 

An inquest jury found Nicolette should not have been required to leave the site to smoke. Provisions should have been made to provide secure smoking facilities or an exemption to the rules, the court heard.

Coroner calls for action amid concern NHS smoke free policy creating suicide risk for mental health patients 

The finding has prompted coroner Michael Spencer to call for action. He has issued a prevention of future deaths report calling on health bosses to review the NHS England smoke free policy. He said action may be needed at a national level to provide clearer guidance or review the law to reduce the risk of patients on mental health wards absconding. 

He added: “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.”

Mr Spencer has sent his report to the Health Secretary, NHS England and the National Institute for Health and Care Excellence.

Thomas Riis-Bristow is the expert medical negligence lawyer at Irwin Mitchell representing Nicolette’s family, including husband, Scott.

Expert Opinion

“Nicolette’s family remain devastated by her death and in particular the circumstances as to how she was allowed to leave hospital.

“They firmly believe that if she had not have been granted unescorted leave that day, she would still be alive.

“Nicolette’s loved ones believe that while well intentioned, the current NHS smoke free policy and its blanket approach is inadvertently creating an unnecessary risk to mental health patients by forcing them to leave hospital grounds where their levels of supervision and safety may be compromised.

“Scott and the rest of the family welcome the coroner’s report. They are calling for lessons to be learned from Nicolette’s death, in order to avoid a similar tragedy and for mental health patients to be better protected.” Tom Riis-Bristow

Nicolette McCarthy's story

On 19 September, 2023, Nicolette, a midwifery matron, was granted 15-minute leave. She left the unit just before 2.40pm. During a patient safety check at 3pm she was recorded as ‘on leave’ rather than AWOL. 

However, an hour later during general patient checks at 4pm, she was identified as absent.

Staff tried to call Nicolette, but her phone was not receiving calls. The hospital contacted police at 5pm to report her missing and Nicolette’s family, who visited her daily, were informed. 

However, Nicolette had been found near Beachy Head around 50 minutes earlier. 

Inquest finds issues in East Sussex mum's mental health care

The inquest heard there was no evidence to confirm that Nicolette’s loved ones had been informed whether she would be granted escorted or unescorted leave.

Sussex Partnership NHS Foundation Trust should also have checked and considered whether it was appropriate for Nicolette to be allowed to take money on leave with her. The failure to class Nicolette as AWOL added to the confusion and there was also a failure to take measures after it was established Nicolette was missing. 

The inquest concluded that Nicolette, who remained a suicide risk, died following “a series of failures in the systems and procedures which should have guaranteed her safety.”

It added that had staff taken “prompt action” on the day she died, Nicolette’s death “could have been avoided”.  

The coroner’s report said that while smoking cessation advice and treatment were offered to patients, evidence suggested they may struggle to give up smoking on their admission. Anxiety associated with giving up smoking could exacerbate their mental health. 

Nicolette's family call for mental health care improvements  

Scott, aged 49, a software development consultant, said: “Nicolette was devoted, loving, caring and empathetic. She was a special person who was beautiful inside and out. Not only were we blessed to have her in our lives but through her work she touched the lives of so many people, helping new families start out in life. There’s not a day goes by that we don’t think of her and miss her. 

“The world is a darker place for not having Nicolette in our lives and it’s almost impossible to find the words to describe the feeling of loss we’ve been left to face. If it wasn’t for the pain we live with every day it almost wouldn’t seem real that Nicolette is no longer with us. 

“We’ll always be upset at the events surrounding Nicolette’s death. We feel that the inquest and the coroner’s report is indicative of the lapses in judgment that Nicolette experienced in her care and that have left our family broken. 

“People with mental health problems are some of society’s most vulnerable people and deserve the best care possible to ensure they return to their family. 

“Sadly, this didn’t happen to Nicolette and it feels like an accidental consequence of the smoke free policy will put more lives at risk. Mental health patients have complex needs and their needs to be an understanding of their specific issues and care tailored to them, not a one size fits all approach.

“However, it’s not just issues around the smoke free policy that the inquest raised concerns about and we continue to have concerns about. 

“The systems and procedures which should have been in place to protect her weren’t. Such policies exist for a reason. If they had been upheld and staff taken the action they needed to when Nicolette went missing, it’s likely she would still be with us today.”

Nicolette also leaves behind grown up children Elspeth Gamble and Duncan Gamble, aged 28 and 25 respectively, as well as three younger children aged between six and 14.

Find out more about Irwin Mitchell's expertise in establishing answers for families with concerns about the care a loved one has received at our dedicated medical negligence section. Alternatively, to speak to an expert contact us or call 0370 1500 100.