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.

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.