David Smith

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into the
death of Mr David Smith,
a prisoner at HMP Northumberland,
on 8 February 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr David Smith died of multiple drug toxicity at HMP Northumberland, on 8 February 2024.
He was 45 years old. I offer my condolences to Mr Smith’s family and friends.
The clinical reviewer concluded that the standard of Mr Smith’s clinical care at
Northumberland was reasonable and equivalent to that which he could have expected to
receive in the community. We do not know the extent of Mr Smith’s drug taking. He had
not disclosed any problems with substance misuse and was not known to use drugs, so
there was little or no opportunity to offer support.
However, a high number of security intelligence reports suggested that Mr Smith was
involved in supplying illicit drugs while employed as a wing cleaner and education orderly. I
acknowledge that punitive action cannot be taken on such allegations without
corroborative evidence. However, I am concerned that this type of information is not
routinely considered when allocating men to wing roles which require a higher level of
trust. As someone trafficking drugs can potentially have a wide and adverse impact on a
wing, houseblock, or indeed the prison as a whole, I consider that there should be a review
of the scope for more robust and auditable employment assessments, not least to mitigate
and manage potential risks.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. Mr David Smith was convicted of murder on 27 January 2014 and sentenced to life
imprisonment. He transferred to HMP Northumberland on 26 October 2022.
2. Mr Smith had been diagnosed with heart failure in 2016 and had other
cardiovascular conditions. Care plans were in place to monitor him, but he
sometimes missed appointments. Mr Smith said that he had no problems with drugs
or alcohol and there was no evidence of him taking illicit drugs at Northumberland.
3. At 9.00am on 8 February 2024, a Prison Custody Officer (PCO) unlocked the
houseblock cleaners’ cells. A few seconds later, a prisoner told the officer who
unlocked them that Mr Smith was dead. The officer immediately returned to the cell
and radioed a medical emergency. Prison and healthcare staff attempted to
resuscitate Mr Smith, but there were signs of rigor mortis and paramedics confirmed
his death at 9.24am.
4. Mr Smith’s death was caused by multiple drug toxicity. The substances found were
bromazolam, buprenorphine and olanzapine, none had been prescribed to him.
Underlying ischaemic heart disease also contributed to Mr Smith’s death.
Findings
5. The clinical reviewer concluded that Mr Smith’s clinical care was reasonable and
equivalent to that which he could have expected to receive in the community.
6. Northumberland has an up-to-date drug strategy, published as a live document,
with a clearly defined action plan. The most prevalent drugs are psychoactive
substances. The prison has implemented various measures to reduce drug
trafficking, as well as building recovery, including photocopying and scanning mail;
acquiring additional drug detection dogs; enhanced gate security; customised
training; and greater collaboration with the police and specialist teams. The latter
has been particularly fruitful in addressing staff corruption.
7. Mr Smith’s personal records reflected that he was helpful and well regarded.
However, during 2023, there were around 20 security intelligence reports
implicating him in the trafficking of drugs and other contraband, such as mobile
phones, partly through his employment roles in the education department and as a
cleaner. There was no evidence that this information was considered when
reallocating Mr Smith to his role as a cleaner towards the end of that year.
8. The security department only assesses prisoners who apply for jobs outside of the
houseblock. Those applying for other jobs are only brought to their attention if they
are of very high interest. We consider that security checks should be made for
positions of trust within the houseblock, to mitigate potential risks.
9. After Mr Smith’s death, the Director issued a notice reminding staff of the key
requirements in conducting welfare checks when unlocking cells.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Recommendation
• The Director should review the process for allocating prisoners to positions of
trust, to ensure there is an auditable record that relevant security information
and potential risks have been fully considered.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
10. HMPPS notified us of Mr Smith’s death on 8 February 2024.
11. The investigator issued notices to staff and prisoners at HMP Northumberland
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Smith’s prison and
medical records, as well as relevant local policies.
13. NHS England commissioned a clinical reviewer to review Mr Smith’s clinical care at
the prison. The investigator and clinical reviewer jointly interviewed four healthcare
staff and a prison officer on 18 April 2024. The investigator also had discussions
with the Head of Security and the Drug Strategy Lead.
14. We informed HM Coroner for Northumberland North of the investigation. He gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
15. The Ombudsman’s office contacted Mr Smith’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Smith’s mother
had no specific questions other than the cause of Mr Smith’s death. A later concern
about his property was resolved in correspondence.
16. We sent a copy of our report to Mr Smith’s next of kin. She did not report any
factual inaccuracies.
17. The initial report was shared with HM Prison and Probation Service (HMPPS). They
accepted our recommendation and reported four factual inaccuracies, which have
been amended.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Northumberland
18. HMP Northumberland is a Category C prison managed by Sodexo Justice.
Spectrum Community Health CIC provides healthcare services. Healthcare staff are
on duty from 7.30am to 7.30pm, Monday to Friday. Tees, Esk, and Wear Valley
Mental Health NHS Foundation Trust provides mental health services. A GP or
Advanced Nurse Practitioner, provided by Spectrum, is available for advice out-of-
hours.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Northumberland was in August and September
2022. Inspectors found that safety and respect had improved since their previous
inspection in 2017. The flow of intelligence was good, processed promptly and
communicated clearly.
20. Inspectors reported that several steps had been taken to reduce the demand for
and the supply of illicit substances, including improved gate security and appointing
a dedicated drug strategy manager. In spite of this, far more prisoners than at
similar prisons said it was easy to get drugs and alcohol; and similarly, a larger
proportion had developed a drug problem at the prison (14%, as opposed to 8%
elsewhere). Managers had appropriately focused on responding to intelligence on
drug and alcohol use. Inspectors noted that there was strong partnership working
between the substance misuse team and the prison, links with the police were good
and the prison was actively addressing staff corruption.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to December 2023, the IMB
reported that there was a regular multidisciplinary meeting to manage risks and
threats from both clinical and operational perspectives; and treatment for substance
misuse remained a priority across the prison. The prison was aware of new,
powerful drugs which could endanger prisoners’ lives.
22. The IMB mentioned the Ombudsman’s attention to the national policy on X-ray body
scanners and was content that the use of such equipment was in accordance with
the policy. They reported on other security processes and stated that, on average,
more than 40 illicit items are found each month. The Board noted that the prison
operates random and suspicion-led mandatory drug testing and considered there
was a robust approach to staff corruption risks. There had been a significant
improvement in both the strategic management and day to day running of
healthcare services.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Previous deaths at HMP Northumberland
23. Mr Smith was the 18th prisoner to die at Northumberland since February 2021.
Twelve of the previous deaths were due to natural causes, five were self-inflicted
and one was drug related. There were no significant similarities between the
circumstances of Mr Smith’s death and those previously investigated.
Psychoactive substances
24. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental processes. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
25. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
26. Mr David Smith was remanded to prison on 10 June 2013. He was convicted of
murder on 27 January 2014 and sentenced to life imprisonment, with a minimum
period to serve of 16 years. Mr Smith spent time at several prisons and transferred
to HMP Northumberland on the evening of 26 October 2022.
27. Due to Mr Smith’s late arrival, a nurse completed a first night safety screen (which
is less detailed than a reception health screen). He noted that Mr Smith had been
diagnosed with heart failure and had previously had a heart attack (in 2016). He
had also been prescribed medications for cardiovascular conditions including high
blood pressure and high cholesterol.
28. Mr Smith said he had no problems with drugs, alcohol, or trading drugs. There was
no recently recorded substance misuse history, therefore he had no contact with the
prison’s substance misuse service.
29. The nurse referred Mr Smith to the long-term conditions nurse. (Mr Smith had a
second-stage health screen before his first reception health screen, on 1 and 3
November, respectively.)
30. Advanced a nurse practitioner followed up the referral on 15 December. She noted
that Mr Smith had been discharged by a cardiologist on 22 March 2021, so a further
hospital referral was unnecessary. Healthcare staff later created care plans for
heart failure and coronary heart disease, but Mr Smith sometimes failed to attend
appointments to monitor his conditions.
31. On 29 November 2022, the prison intercepted mail addressed to Mr Smith,
containing four packages that tested positive for buprenorphine. When questioned,
Mr Smith said he had been “stitched up”.
2023
32. For most of 2023, Mr Smith was employed as a cleaner. (He became an education
orderly in mid-October but reverted to cleaning a few weeks later.) He had regular
meetings with his prison key worker until November. It was consistently noted that
he felt happy and safe, with strong family ties.
33. Mr Smith was on the enhanced level of the prison’s privileges scheme. He
maintained good relationships and was well regarded. Throughout the year, wing
officers frequently commented in his personal records on his positive and helpful
behaviour towards both staff and other prisoners. He was said to be a ‘model’
prisoner, who was working towards becoming a ‘red band’ - a trusted prisoner who
has unaccompanied access to the whole prison.
34. Conversely, numerous security intelligence reports alluded to Mr Smith’s
involvement as a facilitator of illegal drugs. From January 2023, there were 20
intelligence reports linking him to such activity. Notable examples are mentioned in
this report.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
35. In July 2023, an intelligence report noted a lot of drugs were available on
Houseblock 1 and, as an orderly, Mr Smith was implicated in the quick distribution
of them. It also suggested that he was one of two men running the drug network on
the houseblock. Although staff were unable to corroborate the information, the
number of prisoners found under the influence at that time lent credibility to the
allegation.
36. On 1 August, intelligence was received that Mr Smith, and another prisoner
facilitated the drugs trade and had received a new strain of Spice (a term generally
referring to synthetic cannabinoids) undetected by the Rapiscan machine. There
were claims of bullying a prisoner into sampling it. He became very unwell, and
several other prisoners had seizures and convulsions at that time. It was also
alleged that drugs were smuggled via education and some prisoners smuggled
substances in socks and trainers to bypass the body scanners.
37. An intelligence report on 1 October, indicated that Mr Smith kept mobile phones and
drugs, which he hid during cell searches. He received them by mail and in visits,
using codes and pictures to order them. The risk was assessed as high impact and
required a targeted search.
38. An intelligence report entry on 5 November, stated that Mr Smith had been texting
every night for a few days. A further report on 10 November, noted increasing drug
use. Staff suspected that Mr Smith and a prisoner in the adjacent cell (his co-
defendant, also an education orderly) were trafficking drugs from the education
department. The informant alleged the drugs were crack, heroin, steroids, Valium,
diazepam and Spice. It was also noted that there had been previous intelligence
about Mr Smith in relation to drugs and mobile phones in August 2023.
39. At his last meeting with his prison key worker, on 26 November, Mr Smith asked to
return to work as a cleaner and he resumed this role shortly afterwards.
40. Further intelligence reports were submitted linking Mr Smith to drug/mobile
trafficking and other adverse behaviour, but none suggested that he was using
drugs.
Events of 8 February 2024
41. At around 8.45am on 8 February, a Prison Custody Officer (PCO) unlocked
prisoners to attend work, other activities and the medication hatch. He did not allow
Mr Smith’s co-defendant to go to work, as he appeared to be under the influence of
drugs. The PCO was conscious that he had wide access across the prison as a ‘red
band’ prisoner.
42. At 9.00am, the PCO unlocked the wing cleaners. Mr Smith’s cell (HB1-1-11) was
the penultimate and he was lying in bed with the duvet up to his neck. The PCO
greeted him and, as there was no response, he assumed he was still asleep. (He
said it was not uncommon for Mr Smith to stay in bed after unlock and not leave his
cell until around 9.30am.)
43. The PCO started to walk towards the wing office to verify the number of prisoners,
intending to return to conduct welfare checks, when one of the cleaners ran up to
him and said that Mr Smith was dead. He immediately returned to the cell and
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
checked Mr Smith but could not find a pulse. He radioed a code blue medical
emergency (which indicates that a prisoner is unresponsive or has breathing
difficulties) and an ambulance was requested. Another PCO was the first to respond
to the code blue and assisted the first PCO to complete three cycles of
cardiopulmonary resuscitation (CPR).
44. A paramedic at the prison and a healthcare support worker arrived a few minutes
later. They continued CPR, including administering naloxone (a medication that can
reverse the effects of an opiate overdose). They noticed signs of rigor mortis.
45. An ambulance arrived at 9.20am and paramedics confirmed Mr Smith’s death at
9.24am.
Contact with Mr Smith’s family
46. The prison’s family liaison officer and a colleague promptly visited Mr Smith’s
mother. They broke the news of Mr Smith’s death and supported her while she
informed other relatives. The family liaison officer kept in touch with family members
over the following weeks.
47. In line with national policy, the prison contributed to the costs of Mr Smith’s funeral,
which was held on 29 February.
Support for prisoners and staff
48. After Mr Smith’s death, the Director held a debrief with several prison managers.
The staff care team offered support to the staff involved in the emergency response.
49. Each prisoner on Mr Smith’s houseblock was informed personally of his death. Staff
checked the wellbeing of prisoners in the neighbouring cells and reviewed all
prisoners assessed as being at risk of suicide or self-harm in case they had been
adversely affected by Mr Smith’s death. The prison posted notices informing other
prisoners and staff and offering support.
Post-mortem report
50. The report of the post-mortem investigation concluded that the cause of Mr Smith’s
death was multiple drug toxicity. He also had underlying ischaemic heart disease,
which contributed to but did not cause his death.
51. Toxicology tests found the presence of bromazolam (a synthetic benzodiazepine),
buprenorphine (opiate replacement) and olanzapine (used for mental health
conditions). None of these drugs had been prescribed to Mr Smith. The toxicology
report noted that the depressant effects of the buprenorphine on the central nervous
system are likely to have been exacerbated by the presence of the bromazolam, as
well as the likelihood that Mr Smith had used buprenorphine after a period of
abstinence and therefore had little or no tolerance to its depressant effects.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Information received after Mr Smith’s death
52. Prison managers received intelligence that a package had been thrown over the
perimeter fence into the exercise yard for Houseblock 3 and that Mr Smith might
have taken some tablets from it on the evening of 7 February. Staff searched his
cell, but nothing was found.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Drug strategy at HMP Northumberland
53. When Mr Smith arrived at Northumberland, he told healthcare staff that he had no
problems with drugs or alcohol, so he was not offered clinical or psychosocial
substance misuse support. During his time at the prison, security intelligence
reports suggested that he was involved in drug trafficking, but there was no
evidence that he was a drug user.
54. Northumberland has a comprehensive drug strategy, developed collaboratively with
several agencies and published in a live document. It was most recently updated in
June 2024. It is regarded as a key priority and is aligned with the HMPPS drug
strategy, as well as the UK national strategy, “From Harm to Hope: a 10-year drugs
plan to cut crime and save lives”.
55. The main thrust of the drug strategy is to:
• restrict the supply of drugs - by improving security, building intelligence and
targeting criminal networks which aim to bring drugs into prison; and
• reduce demand for drugs - by developing more engaging and interesting
regime opportunities, providing more constructive ways for prisoners to
spend their time and ensuring the balance of incentives encourages
prisoners to make the right choices.
56. Each element of the drug strategy has a discrete and detailed action plan of specific
actions, with timescales and the person responsible for delivery. Governance is via
a monthly drug and alcohol strategy meeting, attended by internal prison
departments and external agencies.
Substance misuse at Northumberland
57. The Drug Strategy Lead told the investigator that, like the national picture, there are
much higher levels of drug use at the prison than they would wish. Test results and
information from healthcare and substance misuse staff indicate that the most
prevalent drugs are PS, with little use of opiates and benzodiazepines.
58. The Head of Security said that there were many variations of Spice. Some were
traded on infused paper, but intelligence also suggested that there was the capacity
for prisoners to make it themselves from component parts, such as vape juice
(which is readily available), hand sanitizer and wipes. The prison was alert to the
risk of nitazenes and several other drugs, which were also manufactured and
widespread in the community, with different levels of potency. They were also
addressing issues around the diversion of prescribed medication, which occurred
predominantly on the vulnerable prisoner wing due the age and health conditions of
many prisoners.
59. One of the substances that contributed to Mr Smith’s death was bromazolam. The
Drug Strategy Lead said that a local illegal pill factory in the community had been
shut down recently and the drug mostly found was bromazolam, packaged to look
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
like benzodiazepines such as diazepam. Around that time, a couple of prisoners
under the influence of drugs had been sent to hospital and tested positive for
bromazolam. (There had also been a huge spike in the community.) Since the
closure of the factory, there had been no further incidents of suspected use of
bromazolam.
Measures to reduce trafficking and the demand for drugs
60. The Drug Strategy Lead and the Head of Security gave examples of initiatives,
processes and improvements to address drug trafficking and substance misuse.
Between 61 and 67 mandatory drug tests (MDTs) are completed each month
(depending on the size of the population) in line with the prison’s contractual
obligations. Outcomes at Northumberland are similar to the national average at
around 23% but the prison is striving to reduce this. Staff also conduct targeted
drug testing. The prison had consistently met all its targets.
61. Prisoners’ social mail is opened and photocopied before distribution, to prevent
trafficking of drugs embedded in paper. Drug detection dogs are used for legally
privileged mail. If they indicate, the correspondence is passed through the Rapiscan
scanner and tested via a small incision in the corner of the envelope. The prison is
part of a pilot scheme in which solicitors are registered and allocated an
identification code, but it is not compulsory for solicitors to participate.
62. Managers had considered making the prison paperless but had discounted this as
they initially thought it would be difficult to manage. However, it might be revisited
following precedents in other prisons and because drug trafficking had become
more sophisticated. As an example, there had been two recent instances of book
deliveries which appeared to be from approved suppliers, packed with hundreds of
sheets of ‘Spice paper’.
63. The prison has introduced enhanced gate security, including X-ray machines; body
portals for visitors and staff to allow searches on entry; a ban on liquids in unsealed
bottles; and are considering allowing staff to bring in vapes (which is not currently
allowed). They have acquired two additional detection dogs, active and passive,
with an increased presence in visits and to strengthen searching correspondence
and parcels. All items must be addressed to a named person and go through
various security processes before being delivered. A body scanner is in use for
prisoners transferring to Northumberland and after hospital visits, if intelligence
suggests there are plans to smuggle contraband.
64. Houseblock 3 was identified as a key supply route. It was a very vulnerable area for
due to its proximity to the fence and road. The prison had tried to mitigate the risk
by being selective about the type of prisoner allocated there, paying attention to
CCTV coverage and adding extra netting over the yard. It is currently closed due to
hazardous concrete.
65. Managers have also implemented new secretion and ‘under the influence’ policies.
The prison can commission its own initial training courses for new staff, which
enables them to customise the training to cover their own local practices and
processes.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
66. The Head of Security felt that a key strength was the development of the
relationship with the police, including the Regional Counter Corruption and
Organised Crime Teams, to break down the ‘county lines’ links in and out of the
prison. Collaboration had led to very successful operations on staff corruption with
several arrests.
Mr Smith’s employment in trusted positions
67. The investigator drew attention to the extensive intelligence suggesting that Mr
Smith had used his employment positions to facilitate drug trafficking and
questioned his suitability for those roles. The Drug Strategy Lead said that the
prison aims to be more proactive about rehabilitation and are therefore less risk
averse than formerly, about who they allocate to positions. In the past, there had
been a general reliance on security markers, but staff now tend to look more at
recent behavioural history and day to day presentation. She acknowledged that it
can be a fine line when taking decisions, but managers have been working to
strengthen the procedures, to ensure that wing staff do not bypass security when
arranging work with the regimes department.
68. The Head of Security said that to encourage better rehabilitation and give the men a
chance to address their issues, there were rehabilitative MDTs and adjudications
were less punitive. There had also been a huge drive on work and education, as
well as purposeful activities. As an example, increasing numbers, particularly
trusted prisoners, were working on agricultural areas.
69. There was discussion about the analysis of security information, as the investigator
was concerned that a facilitator would potentially have a much wider impact on
security than someone who was simply a user.
70. The Head of Security explained that there had been number of cell searches and
examination of Mr Smith’s links, but nothing had been found; Mr Smith had never
been found under the influence of substances; and MDTs had been negative, so
there was nothing to suggest that he was using drugs. As there was no
corroboration of the reports, if Mr Smith had been removed as cleaner, he could
have successfully appealed, given the lack of evidence.
71. The Security Department assesses men who apply for jobs outside of the
houseblock, such as red band roles, workshops, as well as some education and
gardening posts. However, cleaners did not come within this process and there is
an expectation that wing staff know individual prisoners well enough to identify
whether they are behaving appropriately or unusually. As Mr Smith was based on
the houseblock, there was a constant staff presence and CCTV could capture
anything untoward.
72. In these circumstances, the security team only expect residential staff to contact
them if the individual is of high interest. The threshold would be multiple strands of
intelligence and/or the individual was found with contraband such as phones or
drugs. The prison is planning to change the procedures so that risk assessments
are completed at the point of induction, to speed up the process for allocating men
to work.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
73. We acknowledge that there can be a tension between rehabilitation and security
and that it would be unfair to remove a prisoner from employment without tangible
proof of wrongdoing. However, there is no evidence that when Mr Smith was
reallocated to a cleaning role in October 2023, staff took account of the
considerable security intelligence about him.
74. We believe that the prison would benefit from a more transparent and auditable
process to assess the suitability of prisoners for roles within houseblocks which
require them to be trustworthy, particularly those with wider access within the
houseblock. At the very least, there should be a record of whether security
information has been reviewed and whether consideration has been given to
mitigating any potential risks around the possibility of supplying drugs. We
recommend:
The Director should review the process for allocating prisoners to positions
of trust, to ensure there is an auditable record that relevant security
information and potential risks have been fully considered.
Clinical findings
75. The clinical reviewer concluded that Mr Smith’s clinical care was of a reasonable
standard and equivalent to that which he could have expected to receive in the
community.
76. The clinical reviewer found weaknesses in Mr Smith’s clinical management and
healthcare processes after he reported abnormal symptoms on 20 December. This
did not contribute to the cause of his death and the Head of Healthcare has since
made several tangible changes to address the deficiencies highlighted. The clinical
reviewer made a recommendation, unrelated to Mr Smith’s cause of death, about
the management of appointments, which the Head of Healthcare will wish to
consider.
Welfare checks
77. Mr Smith was found seconds after his cell was unlocked. The PCO who unlocked it
said that it was his normal practice to conduct welfare checks shortly after, rather
than during the unlocking process and mentioned that the policy provided for this.
The Director issued a Community Notice within a few days of Mr Smith’s death,
reminding staff of the specific requirements when unlocking cells and performing
wellbeing checks. The detailed expectations in the notice resolve the ambiguity, so
we make no further comment.
Inquest
78. At an inquest held on 25 July 2025, the Coroner concluded that Mr Smith’s death
was due to misadventure.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE