Restricted smoking options increase self-harm risk
NHS England received 2 coroners' reports about this hazard between 25 Jan 2019 and 22 Nov 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“This guidance does not permit the proper use of Section 17 leave.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 5 years 10 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2024Nicolette McCarthy5 years 10 months after David Squire · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify that the NHS England smoke‑free policy creates safety risks for mental health patients by restricting smoking options. They differ in focus: the earlier report concerns misuse of Section 17 leave procedures, while the later report links the policy to increased self‑harm and suicide risk.
David Squire · 25 Jan 2019
“This guidance does not permit the proper use of Section 17 leave.”
Original on judiciary.uk ↗ Nicolette McCarthy · 22 Nov 2024
“the NHS England smoke free policy is placing mental health in patients at an increased risk from self-harm and suicide”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2024 | 0.68 | 0.16 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.