Illegal drugs caused the death of Simon Ludlow at HMP The Mount in November 2023, an inquest jury at Hertfordshire Coroner’s Court has found.
In the jury’s view, the prison’s failure to tackle the flow and availability of drugs probably led to his death. Jurors also found inadequate a “sweep” of his cell that should have sought out such substances.
Mr Ludlow had a past addiction to drugs. However, he had overcome his habit while in a previous prison.
At The Mount, his accommodation was ‘The Annexe’, a unit reserved for trusted prisoners. Somehow, he began using drugs again there.
An opiate overdose left him unresponsive on 18 November 2023, and he needed emergency hospital treatment. After treatment, he returned to the prison.
A thorough search of his cell should have taken place while he was away. The search reported finding nothing. On 23 November, he was found dead.
In its verdict, the jury made clear its criticism of how easily available drugs appeared to be in the prison. It also criticised the cell search itself.
The coroner has indicated that they will submit a Prevention of Future Deaths notice on the case.
Mr Ludlow’s daughter gave a statement that the court heard during the inquest. “When they told me about dad’s death they just said they found nitazenes [synthetic opioids],” she said. “They laid it out to me like it was normal, everyday, and I should know what that means.”
She described her father as a man who “just wanted to be a dad”. She said he was cheeky and a wind-up who often had people in stitches. He was always there when she needed anything, and she could always turn to him for advice.
“I miss having my best friend, the person who I trusted with everything and loved to bits,” she said.
HMP The Mount is a category C prison for men in the East of England. At its last full inspection, in February 2025, inspectors rated safety as reasonably good.
