Ian Smith

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Independent investigation into
the death of Mr Ian Smith,
a prisoner at HMP Stafford,
on 10 April 2023
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, 2025
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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. If my office is to best assist HMPPS in ensuring the standard of care received by
those within service remit is appropriate, then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic failure.
3. Mr Ian Smith died in Royal Stoke University Hospital on 10 April 2023, while a
prisoner at HMP Stafford. His cause of death was recorded as COVID Infection with
chronic obstructive pulmonary disease (COPD) contributing to but not resulting in
the death. Mr Smith also had a long-term diagnosis of multiple myeloma (blood
cancer). He was 62 years old. We offer our condolences to Mr Smith’s family and
friends.
4. The clinical reviewer concluded that the clinical care Mr Smith received at HMP
Stafford was equivalent to that which he could have expected to receive in the
community. She found that his COPD and risk of COVID-19 were managed in line
with national standards.
5. We found no non-clinical issues of concern. We make no recommendations.
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The Investigation Process
6. The PPO was notified of Mr Smith’s death on 10 April 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr Smith’s
clinical care at HMP Stafford.
8. The PPO investigator investigated the non-clinical issues relating to Mr Smith’s care
at Stafford.
9. The PPO family liaison officer wrote to Mr Smith’s daughter to explain the
investigation and to ask if she had any matters that she wanted us to consider. She
did not respond to our letter.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS and Practice Plus Group pointed out one factual inaccuracy, and this report
has been amended accordingly.
11. Practice Plus Group also pointed out some factual inaccuracies with the clinical
review. The investigator passed these onto the clinical reviewer, who amended their
report.
Previous deaths at HMP Stafford
12. Mr Smith was the fourteenth prisoner to die at Stafford since 10 April 2021. Of the
previous deaths, twelve were from natural causes. There are no significant
similarities between our findings in the investigation into Mr Smith’s death and our
investigation findings for the previous deaths.
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Key Events
13. On 12 November 2021, Mr Ian Smith was sentenced to 21 years in prison for child
sex offences and sent to HMP Durham. He had received two COVID-19
vaccinations in the community before entering prison.
14. On 14 December, Mr Smith was diagnosed with terminal multiple myeloma (a form
of blood cancer). He was told the treatment plan. Mr Smith initially declined any
form of treatment and said that he did not want any follow up appointments.
15. On 16 December, Mr Smith was transferred to HMP Stafford. During the reception
process, Mr Smith reported to a nurse that he had a new diagnosis of bone marrow
cancer. He said that he initially refused treatment but that he had since changed his
mind. Healthcare staff arranged for his care to be transferred to Staffordshire
Hospitals.
16. Mr Smith also had asthma and chronic obstructive pulmonary disease (COPD),
which was diagnosed in 2007, and for which he took prescribed medication.
Healthcare staff created a care plan for managing Mr Smith’s COPD, which they
frequently reviewed.
17. On 3 February 2022, Mr Smith started a course of oral chemotherapy.
18. On 16 February, a nurse created a myeloma care plan for Mr Smith.
19. On 24 May, a nurse completed a cancer care review for Mr Smith. She noted he
was on his third cycle of oral chemotherapy and that he understood that his cancer
was treatable though incurable. She made a referral for a Macmillan Cancer Care
Nurse. Three days later, a palliative care specialist nurse reviewed Mr Smith.
20. On 6 June, Mr Smith moved to Stafford’s Specialist Care Unit (SCU) for short term
pain management. That day, at a Multi Professional Complex Case Clinic (MPCCC)
meeting, Mr Smith’s care and treatment needs were discussed.
21. On 16 June, a nurse created a pain management care plan for Mr Smith. She later
conducted a full assessment of Mr Smith’s needs, including his mobility, activities of
daily living, pain, falls risk and continence.
22. On 16 August, Mr Smith received a COVID-19 booster vaccination.
23. On 15 September, Mr Smith was discharged from the SCU to A Wing. Healthcare
staff recorded that his pain relief was working well, and his chemotherapy appeared
to be going well. He continued to see the palliative care specialist nurse at least
once a week.
24. On 6 October, Mr Smith started another chemotherapy cycle.
25. On 17 January 2023, Mr Smith was advised to return to the SCU for a week so that
his pain could be re-assessed, due to the amount of pain relief that he was
requesting. He returned to the SCU on 23 January and a specialist care plan was
created for him that day. During his time on the SCU, a palliative care specialist
visited Mr Smith.
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26. On 6 February, a nurse completed a full assessment of Mr Smith’s needs. He
remained independent and, on 14 February, returned to A Wing.
27. On 7 April, Mr Smith reported a high temperature and vomiting. He was admitted to
the Royal Stoke University Hospital. Restraints were not used during Mr Smith’s
time in hospital. On 10 April, Mr Smith died in hospital.
Liaison with Mr Smith’s family
28. Following Mr Smith’s hospital admission, a family liaison officer (FLO)repeatedly
tried to contact his daughter, but the call could not be connected.
29. On the morning of 9 April, the FLO contacted Mr Smith’s daughter to tell her that he
was very ill in hospital. She spoke to Mr Smith’s daughter after his death and
offered to help with funeral arrangements.
Post-mortem report
30. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Smith’s cause of
death as COVID Infection, with COPD contributing to but not causing the death.
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Findings
31. We found that the clinical care that Mr Smith received was of a good standard and
equivalent to that he could expect to receive in the community. The clinical reviewer
found that Mr Smith’s COPD was managed in line with national guidelines
throughout his time at Stafford. She also identified no concerns regarding his clinical
care related to COVID-19.
32. The clinical reviewer has made some recommendations not directly related to Mr
Smith’s death, which the Head of Healthcare will need to address.
Inquest
33. The inquest into Mr Smith’s death concluded on 29 February 2024, and returned a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman May 2024
Prisons and Probation Ombudsman 5
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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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