Mark Smith

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Mark Smith
on 3 May 2023, following his
release from HMP Risley
A report by the Prisons and Probation Ombudsman
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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 Mark Smith died from multiple injuries caused by a fall from a viaduct on 3 May
2023, following his release from HMP Risley on 28 April. He was 52 years old. We
offer our condolences to those who knew him.
5. We do not know whether Mr Smith deliberately jumped from the viaduct or whether
he fell. He gave no indication to staff at Risley that he had any thoughts of suicide.
Nor did he give any indication to probation staff when he attended his probation
appointment on the day of his release.
6. The post-mortem report noted that Mr Smith had taken heroin and cocaine before
he died. He had a history of substance misuse. He declined support from the
substance misuse team at Risley, but a substance misuse worker warned him
about the dangers of overdose on release. He declined a referral to the community
substance misuse service.
7. We make no recommendations.
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The Investigation Process
8. HMPPS notified us of Mr Smith’s death on 5 May 2023.
9. The PPO investigator obtained copies of relevant extracts from Mr Smith’s prison
and probation records.
10. We informed HM Coroner for Rochdale of the investigation. They 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 daughter to explain
the investigation and to ask if she had any matters she wanted us to consider. She
asked why Mr Smith was moved from one prison to another and why he was
released two days later than planned. We have answered these questions in the
report.
12. Mr Smith’s next of kin received a copy of the initial report. They did not make any
comments.
13. 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 Risley
14. HMP Risley is a mixed sex offender and category C resettlement prison which holds
up to 1061 convicted men. Change Grow Live (CGL) provides substance misuse
services.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Risley was in April 2023. Inspectors reported
that CGL delivered a good, integrated clinical and psychosocial substance misuse
service for prisoners. All prisoners could refer themselves to the service, which was
well advertised throughout the prison. Patients were assessed and support was
developed based on individual goals. One-to-one psychosocial work was delivered,
but staffing pressures meant support had to be prioritised according to patients’
needs and risks. A good range of support for harm reduction was available and
peer workers provided additional information. Joint work between the prison and
community services meant men could receive support on release. Nasal naloxone
(a drug to prevent an opiate overdose) was available.
Probation Service
16. 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
17. On 4 March 2023, Mr Mark Smith was convicted of racially aggravated wounding
and was sentenced to 16 weeks in prison. He was sent to HMP Altcourse.
18. On 30 March, Mr Smith was moved to HMP Risley as this was closer to Rochdale,
the area to which he wanted to be released.
19. Although Mr Smith had a history of substance misuse, he told the reception nurse
that he did not currently have any problems with drugs or alcohol, and that he did
not want to receive support from the prison’s substance misuse service (SMS). He
said that he had never tried to harm himself and that he had no mental health
issues. Mr Smith’s medical records indicate that he experienced drug induced
mental health problems and thoughts of suicide in 2018, but nothing more recently.
20. Due to his history of substance misuse, on 4 April, an SMS peer mentor at Risley
saw Mr Smith to tell him about the service. The peer mentor gave him harm
minimisation advice which included advice on safer injecting and information on the
dangers of mixing drugs. The peer mentor then told him about the risks of overdose
on release, how to recognise the signs and symptoms of an overdose, and what to
do in the event on an overdose. Mr Smith signed the harm reduction form to say
that he understood and did not want to receive any further SMS support at Risley.
21. On 11 April, Mr Smith attended his resettlement board. He completed the harm
reduction and overdose awareness paperwork and said that he did not want to be
referred to the community substance misuse service.
Release from Risley
22. Individuals who are sentenced to 12 months but less than four years in custody will
automatically be released on licence at the halfway point of their sentence. This is
called their conditional release date, and they will not be released before this date
unless they are granted Home Detention Curfew (HDC, a scheme which allows
some people to be released early from custody if they have a suitable address to go
to). As Mr Smith was not suitable for HDC, he was released from Risley on his
conditional release date, 28 April.
23. A nurse saw Mr Smith in reception before he was released. He raised no concerns
and did not mention any thoughts of suicide or self-harm. Prior to going to prison,
Mr Smith held a private tenancy for a flat in Rochdale. He continued with this
tenancy upon his release from Risley.
24. Later that day, Mr Smith attended Rochdale Probation Office for his initial
appointment. His community offender manager (COM) completed his induction and
read through his licence conditions. Mr Smith said that he was annoyed that his
COM had added a licence condition for him to be drug tested. He said that he had
stopped using drugs before he went to prison and that he remained drug free. The
COM explained that his previous substance misuse issues had been linked to his
offending behaviour, and therefore a testing condition must be put on his licence as
a precaution. The COM told Mr Smith that if he provided a positive drug test, then
he would need to engage with Turning Point, the local substance misuse service.
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Although Mr Smith was not happy with his, he signed his licence to say he
understood the conditions. The COM issued Mr Smith with his next office
appointment for 2 May at 1.30pm.
Circumstances of Mr Smith’s death
25. On 3 May, a member of the public found Mr Smith’s body beneath a viaduct in
Rochdale.
26. The same day, the police informed HMPPS that Mr Smith had died.
Post-mortem report
27. The post-mortem report concluded that Mr Smith died from multiple injuries
consistent with a fall from height. It noted that Mr Smith had taken heroin and
cocaine before he died.
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Findings
Risk of suicide
28. Mr Smith died after falling from a viaduct. Toxicology tests show that he had taken
heroin and cocaine before he died. It is unclear whether he deliberately jumped or
whether he fell. There was no evidence that he had any thoughts of suicide or self-
harm during his time at Risley. He also gave no indication to probation staff that he
had any thoughts of suicide when he attended his probation appointment on the day
of his release. He had no recorded mental health issues or thoughts of suicide since
2018.
Substance misuse services
29. Mr Smith had a history of substance misuse. However, while he was in prison, Mr
Smith said that he was not currently using drugs and did not want help from the
substance misuse service. Despite this, the SMS team noted that Mr Smith had a
history of opiate use, so they saw him and warned him about the risks and dangers
of taking drugs. Mr Smith declined a referral to the community SMS team.
30. We are satisfied that Mr Smith was offered appropriate support with his substance
misuse issues and was warned about the risks of taking drugs following his release.
31. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman April 2024
Inquest
The inquest, heard on 29 May 2024, concluded that Mr Smith died by suicide.
6 Prisons and Probation Ombudsman
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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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