17 Feb Simon Ludlow Inquest: Risk of Future Deaths at HMP The Mount
On 16 February 2026, the inquest into the death of Simon Ludlow at HMP The Mount on 25 November 2023 concluded. The Coroner is due to issue a report on the prevention of future deaths. The jury recorded certain issues which contributed to Simon’s death.
Simon Ludlow was transferred to HMP The Mount on 13 December 2022. In the community he was a construction worker. While in a previous prison he undertook work to address substance misuse problems including, as the jury recorded, the completion of a course of methadone treatment.
On 14 August 2023 Simon was transferred to “the Annexe” at HMP The Mount – a special wing for trusted prisoners. The jury recorded that his transfer to the Annexe was because of his clean record, good behaviour and compliance with prison regime. They also recorded his good job in the prison kitchen.
On 18 November 2023 Simon was found unresponsive in his cell. He had suffered a cardiac arrest. He was transferred to Watford General Hospital with a suspected opiate overdose. The jury recorded that after this incident a ‘sweep search’ was done of Simon’s cell, but that it was not a thorough search.
On 20 November 2023 Simon was discharged from hospital and returned to HMP The Mount. The jury recorded that no Wellbeing Review was carried out upon his return to the prison.
The jury also heard evidence that Simon was not seen by the substance misuse team after the suspected opiate overdose – despite an expectation that he would be seen within five days of such an incident.
On 25 November 2023 Simon was found unresponsive in his cell on Nash Wing. He was sadly deceased. His death was attributable to “protonitazine toxicity”.
The jury recorded that there were strategies in place to minimise illicit drugs in the prison but that the levels were above national targets.
They concluded that the entry of drugs into the prison probably contributed to Simon’s death. They also concluded that the extent of any searches possibly caused or contributed to his death.
The Coroner’s Prevention of Future Deaths report is expected to be addressed to the Secretary of State for Justice, David Lammy MP, and the Governor of HMP The Mount.
In a pen portrait read to the inquest, Simon’s daughter set out her shock at visiting her father in hospital after the opiate overdose, and her efforts to understand how he could come by his death. She said:
“When they told me about dad’s death they just said they found nitazines, they laid it out to me like it was normal, everyday, and I should know what that means…
My Dad was the kind of man that just wanted to be a dad. He was cheeky, and a wind up who would have you in stitches half the time…
Anything I ever needed he would be there. He would always be there for me to talk to, for me to get advice from. I miss having my best friend, the person who I trusted with everything and loved to bits…”.
Simon’s daughter was represented in the inquest by DPG’s Rajiv Nair and Cian Murphy of Doughty Street Chambers.
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