Samuel Richards

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Independent investigation into
the death of Mr Samuel Richards
on 20 February 2025, following
his release from HMP Elmley
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. Since 6 September 2021, the PPO has investigated 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 Samuel Richards died from multidrug toxicity on 20 February 2025, the day after
his release from HMP Elmley. He was 43 years old. We offer our condolences to
those who knew him.
5. We found that Mr Richards was offered appropriate support for his substance
misuse issues while at Elmley and after his release.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Richards’ death on 24 February 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Richards’ prison
and probation records.
9. We informed HM Coroner for Mid Kent and Medway of the investigation. They 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 Richards’ next of kin, his father, to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Oxleas NHS Foundation Trust. They pointed out a factual inaccuracy which has
been amended in this report.
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Background Information
HMP Elmley
12. HMP Elmley, located on the Isle of Sheppey, is a category B local prison which
serves the courts of Kent. It holds both remand and convicted men, over the age of
18. It has six house blocks with a mixture of single and double occupancy cells.
Oxleas NHS Foundation Trust is the primary healthcare services provider, and
Change Grow Live provide psychosocial substance recovery services.
Probation Service
13. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
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Key Events
Background
14. On 5 June 2023, Mr Samuel Richards was sentenced to a 12-month suspended
sentence order (SSO) for assault and battery. On 10 November, after breaching the
conditions of his SSO, a judge activated the SSO. Mr Richards was sent to HMP
Elmley.
15. On 4 December, Mr Richards was released from Elmley under the End of Custody
Supervised Licence (ESCL) scheme. The next day, his community offender
manager (COM) initiated recall procedures after he breached his licence conditions.
A warrant was issued for his arrest and on 26 December, Mr Richards was located
and returned to Elmley.
Pre-release planning
16. When Mr Richards arrived at Elmley, he told a nurse that he was not dependent on
drugs or alcohol, although he said he had taken crack cocaine a few days before.
When asked, Mr Richards said he did not want to be referred for substance misuse
support at that time (as he was awaiting the outcome of his upcoming court date).
17. On 3 January 2024, Mr Richards attended an initial substance misuse assessment
with a recovery worker from Change Grow Live (CGL), the substance misuse
service at Elmley. Mr Richards told the recovery worker he first started taking drugs
when he was 14 years old and that five years ago, he started using heroin and
crack cocaine. Mr Richards said that when in the community, he would drink alcohol
daily. Mr Richards told the recovery worker that he would consider attending
substance misuse support groups, however, he was unsure how long he would be
in prison for as he was due in court the next day. When asked, Mr Richards said he
did not want to be referred for substance misuse support at that time. However, Mr
Richards said that he had been working with CGL in the community and would like
support from them after release from prison.
18. The next day, Mr Richards attended court and was convicted of additional violent
offences. He remained in prison while he awaited a date to be sentenced.
19. On 9 October, Mr Richards attended his sentencing hearing and was sentenced to
12 months in prison. Although he had already served the custodial element of this
sentence, he remained in prison under recall procedures relating to a previous
offence.
20. On 10 October, Mr Richards was released from Elmley.
21. On 7 November, Mr Richards was recalled to prison after breaching the conditions
of his alcohol monitoring tag. He was returned to Elmley.
22. When Mr Richards arrived at Elmley, he told a nurse that he had relapsed into
substance misuse on his release and had been using crack cocaine, heroin and
alcohol. The nurse referred him to CGL who saw him for initial assessment later
that day. A recovery worker and a GP assessed that he did not require a prescribed
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drug or alcohol detoxification programme. However, they agreed to monitor him
over the following five days, with a follow-up review scheduled for 13 November.
23. On 13 November, Mr Richards attended his follow-up assessment with a recovery
worker. Mr Richards told his recovery worker that he would like help with his alcohol
misuse and would like to attend an alcohol intervention programme. He said he
would like to attend group work sessions and complete in-cell workbooks.
24. On 10 January 2025, staff suspected Mr Richards was under the influence of an
illicit substance after he was found on the floor of his cell surrounded by vomit. Mr
Richards denied taking or smoking any illicit substances. Staff placed him on a
welfare log and a nurse said she would review him the next morning.
25. The next morning, Mr Richards told the nurse that there was a lot of ‘Spice’ (a type
of psychoactive substance, PS) on his houseblock which he was struggling to
resist. When asked, Mr Richards said he did not want support from CGL at Elmley
but would like to engage with the community SMS service, Forward Trust, after his
release. He was added to CGL’s Connecting Communities service (who support
prisoners prior to release and through to the community for up to three months after
release).
26. On 24 January, a Connecting Communities recovery worker met with Mr Richards
to complete his release plan. Mr Richards told the recovery worker that although he
occasionally used PS in prison, he only used cocaine and alcohol in the community.
Mr Richards said he would like to be referred to Forward Trust based in Canterbury
for ongoing substance misuse support in the community. Staff subsequently
actioned this.
27. As Mr Richards was due to be released from prison homeless, his COM completed
a CAS3 housing referral (a scheme providing temporary accommodation and
support to prison leavers at risk of homelessness) on 14 February. She also
completed a duty to refer application (DTR - where certain public authorities must
notify local authorities that a person who has engaged with them might be homeless
or at risk of homelessness) to Canterbury City Council.
28. On 17 February, Mr Richards was accepted onto the CAS3 scheme. His COM was
notified that temporary accommodation had been secured for him for a period of 84
days at an address in Westgate-on-Sea.
Release from HMP Elmley
29. On 19 February, Mr Richards’ Connecting Communities recovery worker saw him
prior to his release from prison. She gave him details of his appointment with
Forward Trust for 12.00pm on 20 February along with the name of his recovery
worker. Mr Richards was thankful for her help and said he was looking forward to
being released and addressing his issues with alcohol.
30. At 2.30pm, Mr Richards attended his initial appointment at Canterbury Probation
Office. His COM completed his induction, went through his post-sentence
supervision requirements, and Mr Richards signed a copy to say that he understood
them. Mr Richards’ COM gave him the address of his temporary accommodation,
reminded him of his Forward Trust appointment the next day, gave him a food bank
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voucher, and issued his next probation appointment. She issued him with three
separate travel warrants to ensure he could attend all three appointments.
31. At approximately 4.30pm, Mr Richards arrived at his temporary accommodation in
Westgate-on-Sea where he collected his keys and completed his induction.
32. The next day, Mr Richards did not attend his Forward Trust appointment.
Circumstances of Mr Richards’ death
33. On the afternoon of 20 February, Mr Richards met up with a friend in Canterbury.
They attended an address where they purchased crack cocaine and heroin before
returning to the friend’s home address in Canterbury West. At approximately
7.00pm, the friend noticed that Mr Richards was having difficulty breathing and was
grunting. Shortly afterwards, he became unresponsive, so his friend called the
emergency services. At 7.27pm, paramedics arrived and started CPR but
resuscitation attempts were unsuccessful, and they pronounced life extinct at
8.20pm.
Post-mortem report
34. The post-mortem report concluded that Mr Richards died from multidrug toxicity.
Findings
35. Mr Richards was offered appropriate support with his substance misuse issues
while at Elmley. He was also appropriately referred to Forward Trust prior to his
release so he had access to substance misuse support after release.
36. We are satisfied that Mr Richards’ COM took appropriate measures to address his
substance misuse following his release from prison, which included appropriate
post-sentence supervision conditions. She reminded him of his upcoming
appointment with Forward Trust and gave him a travel warrant to ensure he could
attend. She had also arranged CAS3 accommodation for him.
37. We are satisfied that both the prison and probation services did all they could to
manage the risks associated with Mr Richards’ substance misuse.
38. We make no recommendations.
39. At the inquest, held on 30 July 2025, the Coroner concluded that Mr Richards’
death was drug related.
Adrian Usher
Prisons and Probation Ombudsman July 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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