William Smith

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr William Smith,
a prisoner at Landguard Road
Approved Premises,
on 1 October 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, 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. 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.
3. Mr William Smith died on 1 October 2023, at Landguard Road Approved Premises.
His cause of death was acute myocardial infarction (a heart attack) caused by
coronary atherosclerosis (build-up of fats, cholesterol and other substances in and
on the artery walls), with diabetes mellitus and hypertension (high blood pressure)
contributory factors. He was 62 years old. We offer our condolences to those who
knew him.
4. Mr Smith had resided at Landguard Road since his release from prison on 10
March 2023. He had a history of heart disease and diabetes, for which he was
prescribed medication. We did not find any issues of concern in how AP staff
managed Mr Smith.
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The Investigation Process
5. We were informed of Mr Smith’s death on 2 October 2023.
6. The investigator issued notices to staff and residents at Landguard Road informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded. She obtained copies of relevant extracts from Mr Smith’s
probation records.
7. We informed HM Coroner for Hampshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found two factual inaccuracies, and this report has been amended
accordingly.
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Background Information
Landguard Road Approved Premises (AP)
9. Landguard Road AP is a 26-bed approved premises for men in Southampton.
Approved Premises (formerly known as probation and bail hostels) accommodate
offenders released from prison on licence and those directed to live there by the
courts as a condition of bail. Their purpose is to provide an enhanced level of
residential supervision in the community, as well as a supportive and structured
environment. Residents are responsible for their own health and are expected to
register with a GP.
10. Landguard Road is managed by HM Prison and Probation Service (HMPPS). Each
resident is allocated a keyworker to oversee his progress and wellbeing, and to
ensure that they adhere to licence conditions and the AP’s rules. HMPPS staff are
on duty at Landguard Road for 24 hours a day.
Previous deaths at Landguard Road AP
11. Mr Smith was the first resident to die at Landguard Road since 2009.
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Key Events
12. On 25 September 2017, Mr William Smith was convicted of sexual offences and
sentenced to 11 years in prison. He was sent to HMP Exeter.
13. Mr Smith reported a history of heart disease. On 9 October, he was admitted to
hospital for a suspected heart attack, after complaining of chest pains.
14. On 17 November, Mr Smith was transferred to HMP Isle of Wight.
15. On 29 December, Mr Smith complained of tightness of chest and chest pains. He
was escorted to the healthcare unit for further monitoring.
16. On 31 January 2019, Mr Smith was transferred to HMP Woodhill, and, on 27
January 2021, he was transferred to HMP The Verne. During his time at The Verne,
Mr Smith was referred to hospital for heart disease and diabetes.
17. On 11 January 2023, probation staff submitted an approved premises (AP) referral
for Mr Smith. He was accepted at Landguard Road on 22 January. Probation staff
requested an extended AP placement, which was granted.
18. On 10 March 2023, Mr Smith was released from prison to Landguard Road
Approved Premises.
Landguard Road Approved Premises
19. There is no record that Mr Smith experienced any significant health incidents while
a resident of the AP. He registered with a local GP and was prescribed medication
which included bisoprolol (for high blood pressure and heart failure), and metformin
and atorvastatin (for diabetes and elevated cholesterol), which he kept at the AP in
line with local policy.
20. On the evening of 30 September, AP staff noted that Mr Smith did not come out of
his room to socialise with other residents, as he usually did. They also heard him
coughing during the evening. At 11.00pm, during a routine curfew/welfare check a
residential worker at Landguard Road asked Mr Smith about his wellbeing. Mr
Smith reported that he did not feel well. Mr Smith confirmed that he had taken his
medication. He asked Mr Smith if he wanted to speak to the NHS (111 number), but
Mr Smith declined and said he was fine.
21. At 2.17am on 1 October, a residential worker conducted an additional welfare check
on Mr Smith and noted that he was sleeping on his back. He recorded that he had
observed Mr Smith breathing and his body moving.
22. At 7.07am, a residential worker conducted a routine welfare check on Mr Smith in
his room and found him unresponsive. He telephoned for an emergency ambulance
and told them that he believed that Mr Smith had died. He went to Mr Smith’s room
and found his body to be cold to touch. He began cardiopulmonary resuscitation,
but stopped after around two minutes, having concluded that it was futile.
Paramedics attended and confirmed that Mr Smith had died.
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Contact with Mr Smith’s family
23. Mr Smith did not nominate a next of kin at Landguard House and no one was
identified after his death.
Support for residents and staff
24. After Mr Smith’s death, the AP manager spoke to the residential workers and
offered them support. Residents were informed of Mr Smith’s death and offered
support.
Post-mortem report
25. A post-mortem examination concluded that Mr Smith died of acute myocardial
infarction (a heart attack) caused by coronary atherosclerosis (build-up of fats,
cholesterol and other substances in and on the artery walls), with diabetes mellitus
and hypertension (high blood pressure) contributory factors.
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Findings
26. Mr Smith had long-standing heart and diabetes health issues, for which he was
prescribed medication. On the night that he died, he told AP staff that he felt unwell.
Given the symptoms that Mr Smith presented with, an additional welfare check and
offer to call the NHS non-emergency number were appropriate measures of
support. Mr Smith’s symptoms did not indicate that an emergency ambulance was
required.
Adrian Usher
Prisons and Probation Ombudsman May 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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