Craig Smith

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Craig Smith,
on 17 July 2024, following his
release from HMP Rochester
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
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© Crown copyright, 2026
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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 Craig Smith died on 17 July 2024, following his release from HMP Rochester the
previous day. His cause of death was sudden cardiac death caused by cardiac
hypertrophy (walls of the left ventricle become thick and stiff). Chronic cocaine use
was a secondary factor that contributed to but did not cause his death. Mr Smith
was 51 years old. We offer our condolences to those who knew him.
5. Mr Smith had a history of heart disease and was prescribed medication for this for
several years. He was reviewed by a GP shortly before his release from prison.
6. Mr Smith also had a history of substance misuse, including chronic cocaine use. He
worked with the substance misuse service in prison and successfully completed a
methadone detoxification programme. (Methadone is an opiate substitute
medication.) Probation staff arranged appropriate housing for Mr Smith ahead of his
release on home detention curfew.
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The Investigation Process
7. We were notified of Mr Smith’s death on 18 July 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Smith’s prison
and probation records.
9. We informed HM Coroner for Kent and Medway of the investigation. She gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
10. The Ombudsman’s office contacted Mr Smith’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
11. We shared the initial report with HM Prison and Probation Service
(HMPPS). HMPPS pointed out one factual inaccuracy, and we have amended this
report accordingly.
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Background Information
HMP Rochester
12. HMP Rochester is a category C resettlement prison. Oxleas NHS Foundation Trust
provides healthcare services at the prison. Primary healthcare services are
available onsite from 7.45am – 9.00pm Monday – Friday and 7.45am – 6.00pm
weekends.
Probation Service
13. 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.
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Key Events
14. On 23 February 2024, Mr Craig Smith was remanded to HMP Elmley for failure to
surrender to court bail. His prescribed medication included pregabalin (which he
was prescribed for arthritis) and a statin (to lower cholesterol for people at high risk
of cardiovascular disease). At the reception health screen, Mr Smith said that he
was diagnosed with angina around seven years previously. He said that he used
heroin and crack cocaine in the community and a nurse referred him to the
substance misuse team. Healthcare staff identified mild withdrawal symptoms and
prescribed a methadone detoxification course (opiate substitute medication).
15. On 27 February, a GP at Elmley prescribed ramipril (medication for high blood
pressure), which Mr Smith had previously been prescribed in the community.
16. On 29 February, Mr Smith was sentenced to 18 months in prison for driving a motor
vehicle dangerously.
17. On 12 March, probation staff completed an offender assessment plan for Mr Smith.
Mr Smith’s community offender manager (COM) told us that she did not meet Mr
Smith prior to release but communicated with the prison resettlement team who
provided updates on Mr Smith’s progress during March, May and July. Prison staff
reported no immediate support needs for him.
18. On 26 March, Mr Smith returned a home detention curfew (HDC) release address
application. (The HDC scheme allows some prisoners to be released early under
individual curfew restrictions, monitored by an electronic tag.) He requested a
Community Accommodation Service (CAS2 - housing for people who do not have a
suitable address for the term of their licence or Bail Order) referral.
19. On 28 March, Mr Smith was transferred to HMP Rochester. At the reception health
screen, healthcare staff reported that Mr Smith engaged well. He declined to give
any substance misuse history. Mr Smith’s previous prescriptions continued.
20. On 8 April, Mr Smith’s methadone prescription was decreased by healthcare staff at
his request. Healthcare staff recorded that he would complete his course in the
community if not finished before his release. Staff gave Mr Smith harm minimisation
advice. They discussed and agreed his treatment with substance misuse team
nurses. They also encouraged Mr Smith to engage with Change, Grow, Live (CGL –
drug and alcohol recovery services) as this formed part of his treatment plan.
21. On 8 May, Mr Smith attended a pre-release planning appointment. He engaged well
and highlighted that he had applied for HDC and CAS2, which prison staff later
confirmed had been approved. Mr Smith was engaging with CGL and appeared
motivated to continue accessing support in the community. Staff agreed to liaise
with CGL to confirm an onward support plan for Mr Smith. They also referred Mr
Smith to prison staff responsible for supporting men in prison access ID and bank
accounts prior to release. Mr Smith was scheduled for a final pre-release
appointment four weeks prior to his release.
22. On 31 May, a substance misuse nurse assessed Mr Smith. The nurse did not
identify any withdrawal symptoms or other health issues. He recorded that
healthcare staff should monitor Mr Smith’s physical health when he collected his
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medication. A few days later, healthcare staff amended the rate of methadone
reduction, so that Mr Smith would finish the course on 9 June.
23. On 1 July, Mr Smith reported ongoing chest pain that started overnight. A nurse
took clinical observations, confirmed that he had taken his medication for heart
disease, gave him pain relief and booked a GP appointment.
24. On 10 July, Mr Smith attended a pre-release planning appointment. It was
confirmed that he had been accepted for HDC and had been offered a temporary
housing placement in Worthing (until 28 November) in CAS2 accommodation. Mr
Smith’s release plan was updated with this information.
25. On 13 July, Mr Smith attended a GP appointment. He said that he had no current
chest pain.
26. On 16 July, Mr Smith was released from Rochester on licence and HDC. His
licence required him to be supervised by the electronic monitoring team (EMT) on a
tag daily from 7.00pm to 7.00am, at the accommodation in Worthing. In line with
Rochester’s local policy, he was given a one-week supply of medication on release.
Post Release
27. On the day of his release, Mr Smith met with his COM for his initial induction
appointment. He engaged well and the COM said he did not present as being under
the influence of any substances. Mr Smith was in good spirits and said that he was
pleased to be moving to Worthing for a fresh start. Probation staff gave Mr Smith a
travel warrant to Worthing.
28. During the induction, the COM told Mr Smith the conditions of his licence, the
requirements of his release under electronic curfew, and the consequences of
breaching his licence conditions (including potential recall to prison until his
conditional release date). Mr Smith had licence conditions to engage with the local
substance misuse team on a regular basis for assistance in addressing any drug
relapse and alcohol misuse. He had drug testing conditions in order to monitor and
identify any substance misuse relapse.
29. Mr Smith told probation staff that he had attended Chatham Job Centre earlier in
the day. He had started his benefits claim and been given a £900 advance. The
COM said it was positive that Mr Smith had accessible funds and did not present as
being under the influence of any substances. However, she was concerned that
given his long-standing history of substance misuse, the large sum of money given
to Mr Smith immediately on release might lead to his relapse. The COM advised Mr
Smith on the risks of overdosing and to be mindful of his tolerance levels, should he
relapse.
30. Mr Smith’s COM told us that they discussed provision of naloxone (to reverse the
effects of opiate overdose) but Mr Smith was “dismissive” of this and told the COM
he had been drug abstinent for several months and had no interest in drug relapse.
The COM advised Mr Smith to approach the local substance misuse service should
he change his mind.
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31. Mr Smith did not attend his release accommodation on 16 July. His COM therefore
initiated recall procedures.
Circumstances of Mr Smith’s death
32. On 17 July, Mr Smith was found deceased in a flat in Rochester.
Post-mortem report
33. The post-mortem report concluded that Mr Smith died of sudden cardiac death
caused by cardiac hypertrophy (walls of the left ventricle become thick and stiff),
with chronic cocaine use contributing to but not causing the death. The toxicology
report showed a therapeutic level of pregabalin present, as well as cocaine at a
level much below what would usually be fatal.
Contact with Mr Smith’s family
34. We do not know when or how Mr Smith’s family learnt of his death. Probation staff
confirmed that Mr Smith’s family had notified HMP Rochester of his death.
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Findings
35. Mr Smith had a history of heart disease and was prescribed several medications for
the condition. A GP at Rochester reviewed him shortly before his release. Mr Smith
was released with a seven-day supply of medication.
36. Toxicology tests identified that Mr Smith had used cocaine at a non-fatal level in the
time before he died. He had a history of substance misuse and was prescribed
methadone for much of his time in prison. There was good evidence of substance
misuse support and pre-release planning undertaken by prison and probation staff
for Mr Smith while he was in prison. This included securing temporary housing for
Mr Smith in Worthing when he was released.
37. Mr Smith was found deceased within 24 hours of release from prison. Immediately
following his release, Chatham Job Centre had given him an advance payment of
£900 at his first benefits appointment. We share the COM’s concerns that this was
a large amount of money to give to Mr Smith in light of his history of substance
misuse.
Inquest
38. The inquest into Mr Smith’s death concluded on the 11 April 2025. The coroner
gave a narrative conclusion that Mr Smith died as a consequence of cardiac
disease contributed to by cocaine use.
Adrian Usher
Prisons and Probation Ombudsman October 2025
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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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