Mr Tilbury was serving an 8 year prison sentence. At the inquest evidence was heard from his Probation Officer/Prison Offender Manager that Mr Tilbury recognised and accepted that his drug and alcohol issues had been the trigger to his offending and that he was keen to get support to help him address these issues so that he could rebuild his life upon release. He was placed on the 'Wellbeing Wing' so he could have better support for his issues. ln the circumstances it is my statutory duty to report to you. ­ (1) ln May 2018 (16 months before Mr Tilbury's death) HMP the Mount was subject to an inspection by HM lnspectorate for Prisons. The lnspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed. They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison's ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy, and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (

, was high at32o/o.

(2) In the report of the lndependent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison.

(3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol. (a) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison, and the Governor should ensure that key drug issues at the Mount are identified and that the prison's local drug strategy be appropriately revised to address them (5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman's, report four other prisoners have died at HMP The Mount as a result of taking namely:
a. Prisoner X
- died on 1 +th Juty 2ozz
b. Prisoner Y
- died on 25th Ju ly 2022
c. Prisoner Z
- died on 6th January 2023
d. Prisoner W
- died on 261h January 2023 (6) At the inquest the court heard evidence from prison officers that they encountered 'spice' every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019.

(7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was26.21% (compared lo32o/o in 2018). frn" Head of advised that d rugs are brought into HMP The Mount by a number of (9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant risk of future deaths. b ACTION SHOULD BE TAKEN ln my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action.