Recipient

The Mount Prison

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First report 8 Sep 2023•Latest report 8 Sep 2023

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

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Concerns and recipient responses

Statements from The Mount Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Hertfordshire

    AI-generated summary

    KRISTOPHER COREY JAMIE LEE TILBURY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kristopher Corey Jamie Lee Tilbury died in his prison cell at HMP The Mount after smoking a synthetic cannabinoid and consuming alcohol, causing respiratory depression. The report raised concerns that illicit drugs and alcohol remained widely available at the prison, including on a wing for prisoners with substance misuse issues, creating a significant risk of future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Mount Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Weak and unembedded illicit drug supply reduction work

    Wider context from the report

    “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors 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 at 32%. (2) In the report of the Independent 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. (4) 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 14th July 2022 b. Prisoner Y ████████ – died on 25th July 2022 c. Prisoner Z ████████ – died on 6th January 2023 d. Prisoner W ████████ – died on 26th 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) was 26.21% (compared to 32% in 2018). ████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████ (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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Mount Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete required intelligence-led searches

    Wider context from the report

    “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors 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 at 32%. (2) In the report of the Independent 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. (4) 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 14th July 2022 b. Prisoner Y ████████ – died on 25th July 2022 c. Prisoner Z ████████ – died on 6th January 2023 d. Prisoner W ████████ – died on 26th 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) was 26.21% (compared to 32% in 2018). ████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████ (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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Mount Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Widespread availability of drugs and alcohol in the prison

    Wider context from the report

    “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors 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 at 32%. (2) In the report of the Independent 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. (4) 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 14th July 2022 b. Prisoner Y ████████ – died on 25th July 2022 c. Prisoner Z ████████ – died on 6th January 2023 d. Prisoner W ████████ – died on 26th 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) was 26.21% (compared to 32% in 2018). ████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████ (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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Mount Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete suspicion drug tests

    Wider context from the report

    “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors 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 at 32%. (2) In the report of the Independent 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. (4) 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 14th July 2022 b. Prisoner Y ████████ – died on 25th July 2022 c. Prisoner Z ████████ – died on 6th January 2023 d. Prisoner W ████████ – died on 26th 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) was 26.21% (compared to 32% in 2018). ████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████ (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. ”
    Open source report
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Published responses found

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0%All other recipients 58%
0%100%

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47%25%27%<1%<1%
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026