[5][6] After completing his medical degree, Smith returned to Sierra Leone and served as deputy inspector of the Health and Shipping Department.

Smith's warmth and skills as doctor led to promotion and he was eventually appointed Assistant Colonial Surgeon.

[7][8] Smith also lectured in anatomy and physiology at Fourah Bay College from 1879 to 1884, and taught a number of future Sierra Leonean medical doctors including John Farrell Easmon.

Francis Smith was the maternal grandfather of Frances Wright, the first Sierra Leonean female to qualify as a barrister.

Smith had inherited property from his paternal grandfather, Kenneth Macaulay, and owned a house at Gloucester Street.