Justice Committee
Oral evidence: Former Chair of the Independent Advisory Panel on Deaths in Custody: Chair’s end of term report, HC 1260
Tuesday 18 April 2023
Ordered by the House of Commons to be published on 18 April 2023.
Members present: Sir Robert Neill (Chair); Tahir Ali; Janet Daby; Maria Eagle; Stuart C McDonald; Edward Timpson.
Questions 1 - 27
Witness
I: Juliet Lyon CBE, former Chair, Independent Advisory Panel on Deaths in Custody.
Witness: Juliet Lyon.
Q1 Chair: Juliet Lyon, welcome; it is good to see you again. I know that you have come a number of times to give evidence before us. We are very grateful to you for coming now that you have finished your role.
You have heard some of what has been going on in our previous inquiry, but I want to touch more broadly on some of the lessons that you might be able to help us with from your time in post. You chaired the Independent Advisory Panel on Deaths in Custody from 2016 through to January of this year—quite a long run. I know you have been involved in the sector for much longer. How do conditions in prisons now compare with when you started at the beginning of 2016?
Juliet Lyon: I think the warning signs were already there in 2016. Deaths had risen quite markedly in that year. You could see a reflection of the cuts being introduced in staff numbers and regime delivery. It did not feel like a very good year to start.
We decided as a panel to focus on suicide prevention because self-inflicted deaths were higher. We kicked off with a survey of women in prison in consultation with women and followed it up with the Keeping Safe report for about 200 male prisoners, and other experts contributed to that, but it did not feel like, “The Prison Service is on track”; things were beginning to feel like they were falling apart a bit. I think that now it is just awful.
Q2 Chair: It has got worse.
Juliet Lyon: Completely.
Q3 Chair: By how much has it got worse?
Juliet Lyon: I do not subscribe to the hand‑wringing role of prison reformers. I hope that we as a panel were able to do whatever we could to contribute at least to try to prevent deaths in custody, which is our primary focus.
When I say “awful”, the deprivations that happened, particularly during covid, and the extreme imprisonment and the choices made to hold people in isolation have, as you have heard already, continued in some shape or form. We are not seeing prisons with purposeful activity in the same way as people might remember them. We are now seeing high numbers of deaths, unfortunately, both self-inflicted and natural deaths. It is obviously hard to determine how much is due to what happened during the extensive period of covid lockdown, which was more like two years than one; what has happened as a result of having to take extreme action, like Operation Safeguard; and the problem with the workforce and pressures from that direction. It is a very tough call for people who work extremely hard to run and work in prisons.
Q4 Chair: How much worse do you think it had got from 2016 to the pre‑covid situation? You made the point that covid has made it even worse, but was the trajectory getting better or worse up until the covid lockdowns?
Juliet Lyon: Deaths were high in 2016; they went down a little in 2017 and 2018, and began to rise again.
Q5 Chair: Can you put your finger on what the rise was in the pre‑covid lockdowns?
Juliet Lyon: It is difficult to say. I would like to think that because everybody made a particular effort to focus on self-inflicted deaths and suicide prevention it helped for a limited period of time, but clearly it did not help in the longer term.
Q6 Chair: You referred to Operation Safeguard, which came in in November 2022. You said then: “At best the Ministry of Justice has adopted a Mr Micawber ‘something will turn up’ approach to a brewing crisis”—as you described it then—“and at worst it has taken a reckless approach to prison safety.” Those are pretty strong words. Looking at the current pressures on capacity and so on, do you still stand by that? Do you think it has got worse or better? Could it have been avoided? Was it one of the things you were seeing coming down the track?
Juliet Lyon: I think that is the point. It did not come from nowhere. I think there is an expectation that the Prison Service will cope with whatever is thrown at it. I guess it is a classic service in that it is obliged to take whoever is sent by the courts; it cannot refuse entry in the same way that schools can exclude pupils or hospitals can dismiss or fail to accept patients. It is a very reactive service by definition. I do think there is a tendency to assume that it can cope with whatever is thrown at it, but the kinds of things introduced during Operation Safeguard are not safe.
Q7 Chair: Can you give us some examples?
Juliet Lyon: I refer to things like the use of police cells—police deaths are also within our ambit—which take the police away from their main duties. That was and is problematic in so far as people need to know those they are detaining. I guess that one of the main axes for keeping people safe is knowing your detainees and prisoners. The problem when you introduce extreme emergency measures is that people are, for example, brought from the north to the south, where there is a need to use workforce differently, so people arrive in prison not knowing the people they are obliged to take care of. That use of detached duty in itself is worrying.
The other points during Operation Safeguard and continuing today are the health and safety imperatives, including fire standard maintenance, which are hugely important. I know that the director general has made every effort to try to maintain the programme of fire safety, but it has been under threat, and certainly some of the health and safety works required have not taken place.
There are things that could be done. We felt that guidelines could be given to the courts about the use of electronic monitoring for people on remand, given the massive rise in the remand population due to backlogs in the courts, obviously not taking risks with public safety but, at the same time, reducing the pressure. That seemed a very important area.
We have heard a lot—thank you for allowing me to hear it—about workforce and workforce pressures, but some of them have led, for example, to the withdrawal of key work introduced following Lord Harris’s review, which we believed was making a significant difference, in that one prison officer would have the focus of just a few prisoners and consequently would get to know them well and help them to manage their time in prison and make some use of it. Although that key work has been reintroduced, it tends to be mostly on a monthly basis. In most places it is not much more than a quick welfare check. All those things as a network or web of keeping people safe have been reduced.
Q8 Chair: Is that partly a capacity issue, as well as those other things?
Juliet Lyon: Absolutely, and also experience. One in three officers has been in post for less than three years. That is problematic. Certainly, prisoners have said to me on prison visits that they are worried about the safety particularly of young people who have come into the service. The earliest age at which you can enter as a prison officer is 18. That is very young given the requirements of the role.
There are things that could be done about it. In improving retention, I notice that structured staff supervision was mentioned. It was very good to hear that. We asked the team in charge of it to come and talk to the panel some months ago. Their plan seemed to be very solid and useful in supporting staff, but it is only a pilot and it is happening in only about two prisons. I think the budgetary restrictions combined with the very low numbers put the Prison Service in a more perilous position than it was. I worry about that. It is not good to be ending tenure feeling worried about what happens next.
Q9 Chair: I understand that. The Minister told us recently that he will not put a firm end date on Operation Safeguard. Given your criticisms of it when it came in, what is your response?
Juliet Lyon: I feel there should be a firm end date, but there are very few firm things. The service has been characterised more by uncertainty in terms of both what the staff can reasonably expect and what prisoners can expect. I think the in-rush of remand prisoners has contributed in part to that culture, but it is important not just to assume it will be all right, because the projected numbers simply do not match the projected building programme.
Q10 Chair: At the moment you have more numbers than the new build can carry, so the capacity and crowding issues will get worse; is that what you are saying?
Juliet Lyon: I think that is likely to be the case, in so far as we know that the number of spare places, if you like, is vanishingly small. That means there is no room for manoeuvre in the service. If something does go wrong—for example, an incident that leads to the closure of a wing—or maintenance demands, there is nowhere to put people. We should not be in that position.
Q11 Maria Eagle: You paint a worrying picture. The panel’s submission to the output and workforce inquiry emphasised the lack of experience among prison officers now as opposed to, say, 2010. You said that they had 100,000 fewer years of experience in 2022 than in 2010. What effect do you think that loss of experience has on the ability of prisons to keep prisoners safe?
Juliet Lyon: I think it is major, notwithstanding, as I am sure you will remember, that for some prison officers it was time for them to step back and retire; they had become very desensitised by the nature of the role, which is a difficult one to fulfil.
That major loss of experience means that quite a lot of staff who work in prisons have not worked in a prison operating on a normal basis, so they literally have conducted most of the transactions with prisoners through a door. We know that prisoners have been locked up; we heard from the chief inspector about weekends, but in large local prisons they are still largely locked up, and the attempts to reintroduce the regime, which are important, have not really been fulfilled as yet.
A number of staff have not had the experience of engaging with prisoners, which I guess is the best way of putting it. They probably do not know the full potential of using Samaritan listeners—prisoners trained by the Samaritans. The Samaritans themselves have had a long period of time when listeners have had to try to engage, again, through a door, so it has been a very strange period. I think that strangeness is still there, and that is now underscored by the problems of attrition and recruiting and retaining enough people.
Q12 Maria Eagle: What further action would you like to see the MOJ take to try to remedy some of the problems that have arisen in part from the covid lockdowns, but also from increasing pressure and decreasing levels of experience of staff?
Juliet Lyon: You picked on leadership earlier—making certain there is leadership right across the prison estate. Centrally, I think that leadership of the Prison Service is strong. The leadership is clear that there should be limits on what can be expected.
As to what could be done, it is important—maybe the Committee will want to do it—to evaluate the impact of covid, and what happened as a result, on people’s mental and physical health, but also on how a prison operates. It feels like an important way of going back to the basics of what prison is for. How can we make it an experience that at the very least does the least harm and at best is construed as constructive? I think more could be done on the staff training side.
The other area, which often does not get mentioned, is multidisciplinary working, which has proved very fruitful in the past. There is a problem now with gaps in healthcare teams and the use of agency staff. You have the same issues about staff not knowing their prisoners or patients. A lot more could be done to encourage people to work in a more multidisciplinary way and see themselves as teams with a purpose. At worst, it feels simply like coping with or just getting through a day and something to be relieved about.
Q13 Edward Timpson: For what it is worth, I completely agree with you about multidisciplinary working. I have seen other aspects of the care system—for children, for example—where it works very effectively.
Going back to the deaths in custody statistics and looking a little more closely at what lies behind them, we know that in 2021, 371 people died in prison—the highest since current recording practices began in 1978. That was over the period of the pandemic. Within those figures, do you think the Government did enough to prevent death in prison during the pandemic, either from covid itself or for other reasons?
Juliet Lyon: No. I think the Government had choices. I do not want to minimise how incredibly hard it was to be faced with a very large captive population and a pandemic. It is a dreadful thing to have to confront and deal with, and they did it in a disciplined manner. They made a very rapid choice to lock everyone down as their best way of trying to keep people safe.
There were other choices that could have been made. An experiment was conducted by the Lord Chancellor, Robert Buckland, to release the most vulnerable people, which he felt would lead to about 4,000 people being released and would mean there might be a little more room for manoeuvre—in other words, there would be more opportunities to engage with prisoners and more opportunities for some regimes at least and a bit of movement. Otherwise, people would simply be held in their 2 metre by 3 metre cells, but that resulted in only 262 people being released. It included a few women who were pregnant and some people who had particularly difficult conditions that were very susceptible to covid, but it became absolutely mired in bureaucracy as a scheme and lost its way fairly quickly. That choice was missed.
Subsequently, there was a really important choice after the vaccination of everybody in homes for the elderly, including all the staff. That seemed like a brilliant opportunity to apply that to people in detention, particularly in prisons. I fear that that was not considered to be politically palatable. That seemed to be the reason. The clinical advice was very strong. The panel gave that advice, but very much supported the advice given by NHS England, the World Health Organisation and subsequently by SAGE, the Government’s own advisory committee.
Everybody said the same: that it would be a way of keeping people much safer and allowing much more interaction and a healthier environment, given they were a particular population in so far as they had a known high prevalence of respiratory conditions, and they were in very poorly ventilated environments in very small spaces. It seemed obvious that an intervention of that kind, which was comparatively easy to do—that was what the NHS reckoned, in terms of operational staff on the ground—and not very expensive would have been a very good action to take.
I bitterly regret that period. We worked very hard during that time. We were pleased that the operational advice that we were able to give—other than that about how to keep people safe—was taken, but advice about universal vaccination was turned down flat again and again, including by the JCVI and Ministers. It just meant that everything was protracted. People did get vaccinated, but only when they reached the age bracket parallel with people in the community.
Q14 Edward Timpson: I suspect you will have other opportunities to give that evidence to other inquiries.
Juliet Lyon: We made that offer.
Q15 Edward Timpson: In your end-of-term report you said that the pandemic did not explain the consistently high total of deaths in prisons. To go into those figures in a bit more detail, what are the other key causes that account for the number of deaths in 2021 and across the period you were looking at it?
Juliet Lyon: In 2022, there were 301 deaths. Of those, 74 were self-inflicted and 187 were natural deaths. We took a close look at natural deaths—or, as we came to think of them, so-called natural deaths. We did a report with the Royal College of Nursing. We also looked at compassionate release. We found that with natural deaths an earlier diagnosis would have helped. Some conditions and some deaths were preventable, but often the diagnosis had come too late.
During the period of covid, people could not get to hospital very easily; they could not manage their appointments. One person contacted us from prison to say that he had missed three appointments and then had a letter from the hospital saying that he had been taken off the list because he had missed so many appointments. But you have no choice: if you are in prison and there is no escort to take you, that is it, and you have no means of notifying anybody either.
That is an extreme example. People were not getting the treatment they needed, but the reason we put it that way in the end-of-tenure report was that it was not new. We felt more could be done. We were pleased that both the Department of Health and Social Care and the MOJ did respond positively to the report and took some steps to try to improve our health response to people.
Of course, you have to set it in the context of a very rapidly rising elderly prison population. I do not have the figures here, but they are very easy to get. They just show you how many people over the ages of 50, 60 and 70 were in prison during that period and how much that has increased.
Q16 Edward Timpson: I was going to ask you about the different cohorts of prisoners, the risk of death in custody and the ability to have greater earlier intervention and diagnosis. Which parts of the prison population do you think would benefit most from that? You mentioned the more elderly or ageing prison population; is that potentially one of them?
Juliet Lyon: Yes, absolutely. There is a policy on ageing. I do not quite know why it has not been published yet. I know that work has been done on it. A member of the panel, Professor Jenny Shaw, has been contributing to that, but I think it would be important to see what proposals are being made and hopefully within that particular cohort there will be a strong reinforcement of the new compassionate release policy, which we did feel would make quite a significant difference. Is it okay to say something about that now? Would it be appropriate?
Chair: Yes.
Juliet Lyon: The ambit got extended a little bit. As a result of our report, there was a review of compassionate release policy and practice. The ambit was extended to include Alzheimer’s and dementia, which is really important. We were very pleased to see that.
There was advice to clinicians that they did not have to be quite as precise about the exact timing of an anticipated death, which I think helped them clinically to feel they could sign forms saying that a person was close to death but not be precise about when that would be expected, in the same way they had been asked to do before.
There was training for staff and a root-and-branch review of how things were going. We expected, as a result of that, that there would be quite a number of compassionate releases. We were also very pleased that Hospices UK had offered hospice accommodation and seemed very keen to work with the Prison Service.
So it was a surprise to see really no change in the numbers released. I think that last year there were 11 people. The Prisons Minister at the time we did the report said that it would help people not to die while they were waiting to hear, but that is still going on, and there was a continuing refusal to release people. Clearly, if they present a serious risk of danger to the public, that is a good reason not to give compassionate release, but I know that the new chair and the panel will continue to review the reasons for refusal to try to find out quite what has happened and why a new streamlined policy that promised much seems to be delivering pretty much the same thing.
You wanted to know about other cohorts. I have already mentioned the level of uncertainty about remand prisoners and the prospect that, for some at least, electronic monitoring might be a way of helping them to wait for their court hearing.
I should mention IPP prisoners. I know that the Committee has done substantial work on that group. Nine people serving an IPP died last year. It is something one cannot afford to forget. The utter hopelessness of their position means it is very difficult for them to maintain any sense of future; it just seems utterly sad and hopeless. Whether anything can be done—such as reviewing the sentence or better health checks to encourage people—they are in a parlous position. We felt very strongly about it in the report. We gave evidence to you and were pleased by your report, but disappointed by the response.
Chair: You are not the only one.
Q17 Maria Eagle: The rate of self-harm in prisons has more than doubled since 2012, and the rate of self-harm among female prisoners, which has always been higher, has significantly increased since the pandemic. What has driven the increase in self-harm across the prison estate? Is there a difference between the increase generally and the increase in the women’s estate?
Juliet Lyon: Most recently, the increase in the women’s estate is about 16%. There has been a very slight decrease in the number of men. The rates are exceptionally high overall. The total number of self-harm incidents in 2022 was 54,761. Some of the things we have been talking about already—engaging with people and being able to listen to and support them—have been missing, not only during covid but subsequently. That in itself is problematic.
The mental health response has not been as strong as it could be. One of the things we did with the royal medical colleges—the RCGP, the RCN and the Royal College of Psychiatrists—and the mental health colleges was to write to the Secretaries of State for Health and for Justice asking that there be both mental and physical health checks for people following this very long period of isolation. That was not accepted as viable. Maybe it was seen as a valid idea, but not viable in the current circumstances, so it has not happened in the way we hoped it would; nor were the efforts by charities to offer to help taken up, which was disappointing.
Some of that would help, but one of the things that would help more and is not particular to this timing is making certain that women who primarily have mental health needs have those needs met ideally much earlier on as an intervention, and that prison is avoided unless it is absolutely essential that they be sent to custody. It is absolutely right to identify women who self-harm as very problematic.
When I made a visit to Styal with panel colleagues and Lord Bradley, who was chairing a sub-group on self-harm, it seemed obvious that the staff were very exhausted at the time of the visit at some point last year, and there was not the kind of connection you would hope for between the local Samaritans and the safer custody team. Until the new strategy on women offenders becomes a reality, it feels that everything is just in a sort of holding pattern.
Q18 Janet Daby: Both the prisons and probation ombudsman and His Majesty’s chief inspector of prisons have expressed concern that, following deaths in custody, there have been various recommendations, the recommendations have been accepted and there have been action plans, but that learning has not been fully implemented and embedded. What should Ministers be doing to address this, and how would you advise them?
Juliet Lyon: I think it is fair to say that that would also be true of the coroner’s prevention of future deaths report. One of the things we did at the outset of my tenure was to bring all those groups together—the investigators and the regulators—to ask them to talk about that and what they felt would help. They focused very much on the embedding of learning.
One of the most interesting proposals, which was very much endorsed by a recent meeting with bereaved family members, was to engage families far more in the process so that they were not only kept informed about what was happening but consulted and able in some instances to go into an establishment and hear what had changed.
Family members consistently say that the reason they are able to continue with a process that has been very painful is that they do not want it to happen to another family. They do not want another family to suffer as they did. Direct experience of hearing family members talk to staff is unforgettable. When family members came and spoke at the Keeping Safe conference that we held in 2020, the testimony they gave was so powerful, and it is obviously even more powerful when they are in an individual establishment. That is just one mechanism that could be very helpful.
Another more wide-ranging one would be the idea of some sort of oversight mechanism that would review the recommendations made to check on progress and keep a running total of how far the recommendations had been implemented in practice.
Q19 Janet Daby: Who should be held to account for those recommendations not being implemented?
Juliet Lyon: Ministers. It is the only thing one can say. I think there was a recommendation in one report that the Minister should not only be informed of a death in custody but take on the duty or responsibility of ringing the family personally to apologise. I remember one Prisons Minister saying it was impossible to imagine that because there were so many other things in the portfolio, but he did say that it would of course make a difference. I am sure that it would, because sometimes governors will drive across the country to make sure it is done personally. It is important that it is taken with the utmost seriousness. I know that that requirement on a Minister is a huge ask, but it would concentrate minds fantastically quickly.
Q20 Janet Daby: Why do you think the action plans are not being implemented?
Juliet Lyon: I do not think it is a deliberate effort to forget about it, but in part it is a collective forgetting in so far as often, certainly with an inquest, it may happen quite a long time after a death. That is not so with the PPO report, which would be quicker, but sometimes the governor has changed in an establishment, and very often the Minister has changed, so some key people who need to be apprised of the outcome are no longer there.
That is one of the reasons; it is a very practical one. The others are calls on staff time. The basic minimum is obviously done because it is an absolute requirement, but embedding the learning and making sure that the staff are fully aware of what has been said and the recommendations made is difficult. It is a thoughtful process that needs to be seen through from beginning to end.
Q21 Janet Daby: HMP Exeter became subject to an urgent notification procedure for the second time, in November 2022. There have been 10 self‑inflicted deaths in the past four years and rates of self-harm are the highest of any reception prison in England and Wales, which you are obviously aware of. What steps should be taken to prevent further deaths in prison where clusters of self-inflicted deaths are occurring?
Juliet Lyon: That is a really important question. Although the number of deaths has stayed roughly the same, there are more death clusters than before. I know that the Prison Service has developed a formal three-stage process, the third stage of which is to appoint a taskforce to go into the prison and support and help.
We think that independent consultancy could be used to very good effect. We have seen this done at Wandsworth, using the Portman Clinic as independent consultants, where the emphasis—this is a while ago—was very much on drawing solutions from the managers and staff. Multidisciplinary meetings were held, so you would have IMB members and Samaritan listeners alongside staff and governors discussing what had happened, the impact on them and what they believed collectively and thinking what they could do about it. That seemed a way of building back confidence.
In a piece of work that I did at Cornton Vale in the Scottish Prison Service a long while ago, we took a similar tack in trying to help staff who had become virtually paralysed by feeling that whatever they did or said would be wrong and the risks were so high with the women at Cornton Vale that you could not risk doing anything. They were almost immobilised by a number of deaths there.
Rebuilding staff confidence is important. It is worth while to think about using external consultancy because, if it is all done within the management structure, sometimes it is more difficult to be absolutely open about how people are feeling and the trauma people have experienced.
Janet Daby: It is a serious failure. If people are taking their lives in prison and governors and Ministers are not addressing it as they should, it is not valuing prisoners’ lives as much as others, and that is wrong.
Q22 Maria Eagle: The prevention of future deaths report is something in which we showed some interest in our report on coroners. I come across it in various ways in the constituency work that I do. Your end-of-term report highlighted the work that the panel has undertaken on coroners’ prevention future of deaths reports. How do you think the reports can be better utilised to prevent deaths? That is the purpose of them; it is in the name— “prevention of future deaths”. How can we better use them to prevent the same things from happening again?
Juliet Lyon: There are some ludicrously simple things that have already been put in place. I was pleased we were able to help with that. It is simply: who gets the reports? The distribution of the reports turned out to be very patchy. In some instances everyone who should get it got it, including family members, but in other instances it would simply go to the head of a service and might or might not be cascaded to the relevant people.
That is a relatively simple, practical thing, but in the main it has been about the chief coroner taking a role in prioritising the training of coroners in how they write their reports. We have had a number of focus groups with coroners, talking about how they write their reports and the way in which some choose to go into an establishment and talk about the recommendations they made. Others felt that was not appropriate and it was outwith the remit of their role.
Subsequently, there has been a meeting of bereaved family members talking about how much more could be made of these reports and the use to which they can be put. There is reason to be optimistic that they will be used more effectively. It would be useful if the chief inspector looked, as he does with PPO reports, at those reports on inspection visits when reviewing staff progress in particular areas. If they were able to take on the relevant PFD reports as well for that establishment, that would be a helpful thing to do.
Q23 Maria Eagle: The panel published a report on avoidable natural deaths in custody in 2020. You have made some reference to this already and you have talked a bit about the extent to which those deaths are preventable. It has a lot to do with healthcare. What progress do you think has been made on the panel’s recommendations on healthcare in prisons?
Juliet Lyon: It is one of those things where I think there was initial progress. Because we did it jointly with the Royal College of Nursing, that was helpful. It gave the RCN an opportunity to focus on making prison nursing more of a clinical specialism. That was something in which the chief nurse was interested at the time.
That was just before covid. Since then, there has been a struggle fully to staff healthcare units and not resort to agency staffing. I think it has been much more difficult for them to continue with a coherent response. I am hoping that will happen, because the recommendations we made were accepted at the time, as you said, but whether they have all been implemented is something that the panel could choose to monitor. I hope it does choose to do so.
Q24 Stuart C McDonald: May I turn to the issue of deaths from drugs in prisons? Some of the statistics seem quite frightening. It seems you are more likely to die of drugs in male prisons compared with the general population, and the first couple of weeks after you leave prison seem to be particularly dangerous. What needs to be done to address both those problems—deaths within the prison system, and the handover when people are released from prison and the first couple of weeks outside?
Juliet Lyon: Because of Dame Carol Black’s report and the report we did with the Royal College of General Practitioners, there is a very strong basis for making sure there is a health lead on this. That is important because it ensures continuing healthcare.
I did see from the figures produced by the ONS recently that the number of drug-related deaths in prison now outweighs the number of drug-related deaths in the community for the first time ever. We wanted to see those figures and asked that the ONS take that interest, and I am glad it did.
Because of those reports, one would hope there was sufficient focus. There is also opioid-substitute treatment available. That is being used increasingly in establishments. So it should get better, but it has been and remains at the moment a very serious problem.
Q25 Stuart C McDonald: Is there anything in particular that you want to say about the process of somebody leaving prison and the first couple of weeks being particularly catastrophic in terms of the number of deaths? What is going on in that handover? Is it lack of investment, lack of continuity or lack of co-operation between health provision inside and outside?
Juliet Lyon: Transitions are always the riskiest times, in terms of any deaths in custody in the first few days in an establishment and any transition including release. There have been deaths in approved premises run by probation, as you know, and a number of deaths of both women and men following custody, often because they are exposed to a substance having been detoxed from it.
More could be done to make that transition smoother and ensure that for anybody on a prison treatment programme the treatment programme continues outside. That should happen because of the increased use of probation supervision. I am pulling a face because I do not know why it is not happening in the way it should.
Q26 Stuart C McDonald: We have already touched on the issue of suicides. At various points the board has made recommendations, in its reports in 2017 and in 2020. To what extent do you think the Government have implemented those recommendations—even practical things like the removal of ligature points and so on? Are there grounds for optimism that things are being improved? Or is there still a long way to go?
Juliet Lyon: There have been some improvements; it is not all bleak. One has to bear in mind that people in prison custody are unusually vulnerable to taking their own lives. The stats are quite extraordinary. Twenty-one per cent. of men in prison and 46% of women in prison have attempted to take their own lives at some point before custody. That compares with just 6% of the general population. So a fifth of men and half of women in prison have tried to take their own lives. This is why it is so important to avoid custody for people who do not need to be there, but also to make sure that people are cared for by excellent prison officers and healthcare staff.
Having said that, some of the recommendations that we have made have absolutely not been fully implemented—for example, the central recommendation about improved mental health support still remains. I think there is a greater effort to engage families. One of the positive things that came out of the period of time when people were contained during covid was the use of phones in prison cells and improved contact with families, even though it was not face to face at that stage. There is a very strong awareness of the first 30 days being a very risky period.
There was one very practical thing I was really pleased about. It was tiny, but I like to think it may have saved a few lives. Women we consulted at Foston Hall, I think, told us about pin phone numbers: “When we move to another prison”—they were moved quite often—“our pin phone numbers are taken away. We cannot remember our family’s numbers and friends’ numbers; we cannot remember counsellors’ numbers.” We queried that because women’s prisons all have the same security classification, so there was no reason whatsoever to strip off these numbers as they move from one prison to another. The Prison Service stopped doing it, which was terrific.
I guess it would be harder to work it out with men because they might be moving to a higher security classification and there would be a rationale for it then, but those women at least, as soon as they were moved, or even knew they were moving, could ring a friend or contact their family and let them know. That maintained something of a network to support them through difficult periods.
There have been some very small practical changes that hopefully have had a bigger impact, but there is so much more to do. I know that the panel is now contributing to the DHSC new 10‑year suicide prevention plan, and there has been a big consultation with people in prison and the Samaritans as a basis for that.
Q27 Chair: We may well have a vote fairly soon. It may be that for some specific questions it is easier to put them in writing. I do not know what Members think. Before we get interrupted by about three Divisions coming along, which will take some time, please give us a sense of what the achievements are and what you say are the principal challenges for your successor and the team.
Juliet Lyon: I can only say that I wish the achievements were greater. If you just take the period 2016 to 2023, there was a reduction in the number of deaths, as it happens, between those years and in the rate of deaths in a prison setting, but really the deaths have climbed or pretty much remained the same. They have fluctuated. I would love us to be able to tell you that this has led to a marked decline in deaths. I fear that until and unless the Prison Service is able to be properly staffed and resourced and is seen as a really important public service, with all that that that involves, it is really difficult for them to keep people safe.
One of the reasons there is an Independent Advisory Panel on Deaths in Custody is that we are there to remind people absolutely all the time of their human rights obligations. The phrase is that they have to take active steps to protect lives. That is what the panel has to keep doing. It has to keep coming up with the best research possible, both national and international, and the best advice it is able to deliver.
I do not want to talk too much about covid—I already have—but it was a real revelation to me that Ministers could not accept the advice that was coming from every quarter because they feared that the public would not find it acceptable. I do not believe that was a good enough reason to put people’s lives at risk.
That is a brief reflection. I think the natural deaths report, compassionate release changes and some of the things we have been able to do on policing and immigration have all been positive, but there is more to do.
Chair: That is very helpful. I am very grateful for all the engagement you have always shown to our Committee and the engagement we have had personally as well. You have put in an awful lot of public service over a considerable period in this field and we ought to recognise that. Thank you very much for it. We wish you the very best for whatever future plans there are. Thank you so much for what you have done and will do, and for your evidence today. We are very grateful to you.