Jason Lyons

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jason Lyons,
on 26 September 2023,
following his release from
HMP Brixton
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Jason Lyons was found deceased at his home on 26 September, following his
release from HMP Brixton on 15 September. His body was severely decomposed
and the cause of death was unascertained as a result. Mr Lyons was 46 years old.
We offer our condolences to those who knew him.
5. Mr Lyons had a long history of offending and had served several prison sentences
for breaches of a restraining order. He was diagnosed with anxiety and depression
but told prison staff he had no thoughts of suicide or self-harm. There was nothing
to indicate this had changed in the time leading up to his death.
6. Mr Lyons chose not to engage with prison substance misuse services and told them
that he was substance free. Following his release, he did not attend initial or
rearranged appointments at his local probation office. While we are satisfied that
there were no missed opportunities to identify further support requirements, Mr
Lyons’ death is a reminder to HMPPS staff of the potential vulnerability of those
who choose not to engage with support services.
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The Investigation Process
7. We were informed of Mr Lyons’ death on 2 October.
8. The PPO investigator, obtained copies of relevant extracts from Mr Lyons’ prison
and probation records.
9. We informed HM Coroner for London West of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
10. Mr Lyons did not have a recorded next of kin.
11. The initial report was shared with HM Prison and Probation Service
(HMPPS). HMPPS pointed out one factual inaccuracy and this report has been
amended accordingly.
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Background Information
HMP Brixton
12. HMP Brixton is a Category C prison and holds men who have been convicted and
have less than 2 years left to serve in custody. Practice Plus Group provides
healthcare services to the prison.
Probation Service
13. 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
14. On 8 January 2022, Mr Jason Lyons was sentenced to 48 weeks in prison for
breach of a restraining order. He was sent to HMP Wormwood Scrubs. Mr Lyons
was later released from prison but recalled to Wormwood Scrubs for a further
breach of the restraining order. He was later transferred to HMP High Down.
15. On 6 March 2023, probation staff completed a licence and post sentence
supervision (PSS) order for Mr Lyons, which set out his licence conditions on
release from High Down. The PSS order commenced 10 March 2023 and expired
on 11 March 2024. Mr Lyons agreed to this and signed it.
16. On 10 March, Mr Lyons was released from High Down.
17. On 11 May, Mr Lyons was recalled to Wormwood Scrubs for breach of his PSS
conditions. He was seen by healthcare staff and the medical records said he had
anxiety, depression and asthma, and was prescribed medication for these. He had
no history of self-harm.
18. On 15 May, Mr Lyons met with the pre-release team and completed a review. Mr
Lyons told prison staff that he had no current issues with substance misuse having
recently stopped using heroin , so did not require support. The community offender
manager (COM) confirmed that Mr Lyons had completed a drug intervention course
six months previously and said that he no longer used drugs. Mr Lyons also told
probation staff that he was physically well but struggled with depression and
anxiety. He said that he had seen the doctor in custody and was prescribed
mirtazapine (an antidepressant). Mr Lyons declined a referral to the mental health
in-reach team and told probation staff that he “could manage”.
19. On 30 May, the prison offender manager (POM) sent a letter of introduction to Mr
Lyons.
20. On 27 June, Mr Lyons was transferred to HMP Brixton. He told healthcare staff that
he had no thoughts of self-harm or suicide and they identified no risks or concerns.
21. On 4 July, Mr Lyons met with the prison resettlement team and attended the
employment hub (dedicated spaces in prisons where prisoners can focus on
employment). He told staff that he had a bank account and release identification. Mr
Lyons said that he had confirmed release accommodation. He required a CV and
disclosure letter, and was added to an employability course waiting list. Mr Lyons
said that he had previously worked in construction and was interested in going back
to that work sector or working in retail. He had attended a number of prison
courses, including first aid, manual handling, fire safety, street work and a personal
track safety course. Mr Lyons completed a construction sub-contractor referral form.
22. On 20 July, the resettlement team referred Mr Lyons for tenancy support and the
COM helped Mr Lyons with email job searches. An updated assessment by the
prison was sent to the COM who placed the information on the probation
database.
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23. On 27 July, Mr Lyons spoke to prison staff from the Offender Management Unit
(OMU). He told them that he would like a job after prison and would like his COM to
make a referral to employment providers who worked with ex-prisoners. Staff
passed this onto Mr Lyons’ POM.
24. Mr Lyons’ probation officer told us that on 7 September, Mr Lyons was transferred
to a new probation officer. The new probation officer was on leave from 4
September to 15 September inclusive. As Mr Lyons’ new probation officer would not
return to work until 18 September, a request was made for another probation officer
to see Mr Lyons on his release on 15 September.
Post Release
25. On 15 September, Mr Lyons was released from prison on licence. As he had not
worked with the substance misuse team at Brixton, and had told staff that he no
longer used drugs, he was not offered naloxone (used to reverse the effects of
opioid overdose) on release. As he had chosen not to work with the mental health
team in prison, there was also no onward referral to community mental health
services. There is no indication in his prison records that Mr Lyons had used drugs
while in prison or experienced deteriorating mental ill-health. He was not managed
under suicide and self-harm procedures (ACCT) at any time.
26. Mr Lyons was released on post-sentence supervision (for adults who receive a
custodial sentence of less than two years). His supervision requirements included
testing “as reasonably required” at an addiction recovery unit for drugs and alcohol
use. (Mr Lyons was not given a date to attend for a first test.)
27. Mr Lyons was released to live in a tenancy in Brentford. He told a housing officer at
Brixton he had lived at this Brentford tenancy for 22 years.
28. Following his release, Mr Lyons contacted probation staff by telephone and
informed them that he was unable to attend his initial appointment later that day.
(Mr Lyons did not give a reason why he could not attend the appointment.) Mr
Lyons’ new probation officer told us that Mr Lyons was asked to attend a second
appointment on 18 September, which he also did not attend.
29. On 19 September, after her return from leave, the probation officer raised concerns
with her manager that the address Mr Lyons was released to was near to the
subject of the restraining order that Mr Lyons had already breached. The probation
officer also identified issues regarding Mr Lyons’ risk of reoffending.
30. On 20 September, the probation officer sent an initial appointment letter to Mr
Lyons, with instructions requiring him to attend the local probation office on 26
September. (Mr Lyons told probation staff that he did not have a personal telephone
number on which he could be contacted.) Probation staff also contacted Hounslow
Council to start the process to rehouse Mr Lyons away from the subject of the
restraining order.
31. There is no record of Mr Lyons’ movements after his release until his body was
found on 26 September. The Coroner’s report identified that he introduced himself
to a neighbour on the day he was released. The same neighbour spoke to him in
the evening of that day when he said he was feeling low and mentioned his
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girlfriend had left him. His neighbour said that they did not see Mr Lyons again after
that day.
Circumstances of Mr Lyons’ death
32. On 26 September, Mr Lyons’ neighbour looked through his bathroom window and
saw him lying in the bath. His neighbour was concerned and telephoned the police,
who found Mr Lyons deceased. Under Mr Lyons’ body, police found a mirror and
silver foil with a burnt ash like substance on it. (We do not know if the substance
was tested so were unable to confirm what it was.)
Post-mortem report
33. The post-mortem report concluded that Mr Lyons’ cause of death was
unascertainable. This was due to Mr Lyons’ body being severely decomposed when
he was found.
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Findings
34. The cause of Mr Lyons’ death is unclear. He had a history of substance misuse in
the community but declined support from the prison substance misuse services. He
told prison staff that he no longer used drugs and did not consider it necessary to
engage with substance misuse services.
35. Mr Lyons had not been managed under ACCT procedures while in prison. He had
some risk factors for suicide and self-harm, including a diagnosis of anxiety and
depression. We are satisfied that there was little to indicate that he was at
heightened risk in the time before his release from prison.
36. On the afternoon of his release from prison, Mr Lyons had an induction appointment
at his probation office, which he did not attend. A second appointment was
arranged, which Mr Lyons again did not attend. His COM told us that these
arrangements were made during her leave. She wrote to Mr Lyons following her
return to arrange a further appointment, which was on the date that he was found to
have died. It is possible that Mr Lyons had died by the time of his second
appointment.
37. We are satisfied that there was no specific risk information (relating to substance
misuse, mental ill-health or risk of suicide and self-harm) that should have been
shared between prison and probation staff. When he did not attend his induction
appointments, probation staff took prompt action to arrange follow-up appointments.
Nevertheless, the circumstances of Mr Lyons’ death are concerning and it is
possible that he was dead for ten days or more before his body was found. This
case is a reminder to HMPPS staff of the increased vulnerability of those who
choose not to engage with support services or do not attend release appointments.
38. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
Inquest
39. The inquest into Mr Lyon’s death concluded on the 15 April 2024. The coroner
reached an open conclusion.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Prisons and Probation Ombudsman 7
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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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