Smith, Ryan

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ryan Smith
on 27 October 2022,
following his release from
HMP Winchester
A report by 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
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© Crown copyright, 2024
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Summary
1. 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.
2. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Ryan Smith died from a drug overdose on 27 October 2022, following his
release from HMP Winchester on 25 October. He was 39 years old. We offer our
condolences to those who knew him.
5. Mr Smith completed a methadone (heroin detoxification) programme in prison but
declined all other support offered by the prison’s substance misuse service. He was
therefore not referred for support on release.
6. Mr Smith was released homeless, but we are satisfied that his community offender
manager made the appropriate referrals.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Smith’s death on 27 October 2022.
9. The PPO investigator obtained copies of relevant extracts from Mr Smith’s prison
and probation records.
10. We informed HM Coroner for Hampshire of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
11. The Ombudsman’s family liaison officer contacted Mr Smith’s partner to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Winchester
13. HMP Winchester is a category B local prison which holds up to 564 male prisoners
who have either been convicted or are on remand. The prison also has a separate
category C unit. Practice Plus Group provides physical health, mental health and
substance misuse services.
Probation Service
14. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Winchester was in March 2022. Inspectors
reported the substance misuse team provided a good service and prisoners leaving
prison were offered harm minimisation advice and naloxone training (a treatment to
reverse the effects of opiate overdose). The service liaised with the community to
make sure discharge planning was effective and included details of their prescribed
medication.
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Key Events
16. On 27 February 2021, Mr Ryan Smith was remanded in prison, charged with actual
bodily harm. On 26 March, he was convicted and sentenced to 19 months in prison.
He was sent to HMP Winchester.
17. On 7 January 2022, Mr Smith was due to be released from Winchester, however he
was held on remand pending further charges for drug related offences.
18. On 2 March, Mr Smith was released from Winchester on bail with conditions to
reside at Dickson House Approved Premises.
19. On 17 March, Mr Smith’s community offender manager (COM) recalled him to
prison due to him breaching his licence conditions. On 19 March, Mr Smith was
returned to Winchester.
20. When Mr Smith returned to prison, he asked to be placed on a heroin detoxification
programme. He was prescribed methadone (an opiate medication used as a heroin
replacement) in reducing doses until 6 May, when he took his last dose.
Pre-release planning
21. On 21 September, Mr Smith’s COM made a referral to an Approved Premises (AP).
However, on 13 November after speaking to the AP manager, the COM decided to
withdraw the referral for Mr Smith due to Mr Smith’s lack of motivation and
willingness to attend an AP on his release. Additionally, there were concerns about
his compliance and engagement when he was at an AP previously, with ongoing
issues around drug use. The COM thought it would be very unlikely that Mr Smith
would engage with an AP on release.
22. On 4 October, Mr Smith’s COM completed a Duty To Refer (DTR) to Basingstoke
Council as Mr Smith was of no fixed abode. (The Homelessness Reduction Act
2017 requires prisons and probation services to refer anyone who is homeless or at
risk of becoming homeless within 56 days to a local housing authority.) There is no
evidence documented that the council acknowledged or responded to this referral.
23. The same day, the COM also completed a referral to Ingeus accommodation
(providing advice and support to those who are homeless and need to find
accommodation).
24. On 19 October, a practitioner from Ingeus met with Mr Smith for his initial
assessment. During this assessment, Mr Smith said that he did not want to go into
supported accommodation because he thought there would be a lot of drug use
there, and he did not want to surround himself with that lifestyle again.
25. On 20 October, the practitioner sent an action plan to Mr Smith’s COM outlining
what work she had planned to complete with Mr Smith to support him in accessing
appropriate accommodation on release. The action plan was approved by the COM.
26. Mr Smith declined to engage with the support offered by the substance misuse
team in prison and signed a withdrawal form. Therefore, they were unable to
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arrange any throughcare because they did not have consent from Mr Smith to
contact the community team Inclusion (a recovery service supporting those affected
by drugs and alcohol), to be able to arrange an appointment for him. (Consent
forms are completed and signed by the prisoner as part of the assessment process
which Mr Smith declined. Prisoners are able to continue with their methadone script
without engaging in additional support from the team.)
Post-release planning
27. On 25 October, Mr Smith’s COM spoke with staff at Winchester, who told her that
Mr Smith had been given unconditional bail and would be released that evening.
They asked the COM for reporting instructions for the following day. The COM told
them that Mr Smith would be seen by her colleague and provided an appointment
for 26 October at 2.00pm.
28. On 26 October, Mr Smith attended his initial appointment at the Basingstoke
Probation and CRC Office. Mr Smith admitted that he had used illicit drugs in prison
and that his drug test may be positive. Mr Smith said that he no longer injected
drugs as he knew this would be extremely risky, due to the hole in his leg from
previous injecting. Mr Smith said he thought he would die if he injected drugs again.
During this appointment, Mr Smith was encouraged to present himself to Inclusion
(the local drug and alcohol service).
29. That day, Mr Smith attended Inclusion and the next day he was allocated to the
Criminal Justice Intervention Team (CJIT- provide clinical and therapeutic
interventions to those involved in the criminal justice system). The team were due to
call him for an assessment but, unfortunately, Mr Smith died before this happened.
30. Due to the short notice of Mr Smith’s release, no accommodation had been sourced
for Mr Smith, but he said he had a few friends he could stay with temporarily.
31. During the probation appointment, Mr Smith was advised to call Ingeus
accommodation and to also attend Julian House (an outreach team who work
directly with those that are homeless and help them find suitable accommodation)
for additional support. Mr Smith asked for this to be written on the back of his
appointment slip so that he would not forget.
32. On 27 October, Mr Smith had an appointment booked with Ingeus to discuss the
action plan, however he did not make it to the appointment.
Circumstances of Mr Smith’s death
33. On 27 October, Mr Smith was found dead by his friend. Mr Smith’s friend told the
police that he and Mr Smith had smoked crack, injected heroin and had taken
cocaine the previous night.
34. The same day, the police informed HMPPS that Mr Smith had died.
Post-mortem report
35. The post-mortem report concluded that Mr Smith died of central nervous system
depression (when the body’s neurological functions slow down) caused by a high
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level of morphine in the blood, along with pregabalin, zopiclone and gabapentin.
Mild cardiac hypertrophy (a disease in which the heart muscle becomes thickened)
and chronic obstructive pulmonary disease (COPD - a group of serious lung
diseases that cause breathing difficulties) were listed as contributory factors.
36. At the inquest held on 28 November 2023, the coroner concluded that Mr Smith’s
death was accidental.
Findings
Substance misuse services
37. Mr Smith declined to engage with substance misuse services in prison. Therefore,
no referral was made to community substance misuse services prior to his release.
38. However, the COM encouraged Mr Smith to attend the Inclusion office for support
which Mr Smith did, and they were very prompt to allocate Mr Smith to the CJIT,
offering him an appointment to be assessed. However, Mr Smith died before he
was able to have an assessment with CJIT.
39. We are satisfied that prison and probation staff offered Mr Smith appropriate
support with his substance misuse issues.
Accommodation
40. While prison and probation staff appropriately referred Mr Smith for accommodation
in a timely manner, he was released homeless. The provision of suitable
accommodation for people leaving prison, particularly for those with complex risks
and needs, is an issue that extends beyond the remit of HMP Winchester and local
probation services. Housing, accommodation services and the local authority may
want to be aware of the issues raised in this case.
Adrian Usher
Prisons and Probation Ombudsman January 2024
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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
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