(1) Emergency Cell Bell System During the evidence there was CCTV footage of other prisoners silencing Mr Ruggiero's cell bell from outside his cell door. The jury found that this hampered the ability of prison staff to respond and react to Mr Ruggiero's needs and distress in the hour or so before his being found unresponsive in his cell. I was told in evidence that anyone (other prisoners or staff members) can silence an emergency call bell at the push of a button outside the relevant cell door and there is no mechanism or system in place to ensure that the cell bell can only be silenced by staff. The evidence was that as and when a cell bell is silenced, staff assume that the call for assistance has been answered. There was clear evidence that this situation has not changed in any way since November 2024. As a result the emergency cell bell system remains highly vulnerable to both misuse and abuse. In my opinion, this raises a significant risk of future deaths if action is not taken.

(2) ACCT documentation and staff approach to this In Mr Ruggiero's case some ACCT documentation (his Care Plan) had not been completed. The jury found that this, "led to missed opportunities for all staff to understand Mr Ruggiero's triggers and other vital information in order to care for him" under the ACCT. I heard evidence that there are now additional systems in place in terms of an 'ACCT reassurance process'. However, during the course of the inquest two supervising prison officers gave evidence to the effect that they had the opportunity to complete Mr Ruggiero's care plan, should have done so, but still did not do it. On further exploration in the evidence, there appeared to be a view that some staff still did not see the value in the completion of such documentation. While there have been some steps taken that are aimed at reducing the risk, I am not sufficiently reassured that sufficient action has been taken. In my opinion, the attitude of some staff towards the value of such documentation remains a real and valid concern that continues place particularly vulnerable prisoners at risk. (3) 'Code Blue' During the evidence in the inquest hearing there was clear confusion among prison staff regarding the calling of a 'code blue' in an emergency situation. That confusion included if / when to call a code blue and how to do so. The evidence was such that not only was there confusion at the time of events in November 2024, but that it persisted to date. I was told in evidence that the prison has issued more guidance to officers in this regard, but I was insufficiently reassured that this guidance has either had time to take effect or has taken affect at all. There is clear evidence that this presents a risk of future deaths and I am of the opinion that action needs to be taken.

(4) Staffing / Experience / Communication etc. The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new in post and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'. In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity. Opportunities to increase formal observations or notify health care were missed. Staff communications failed to relay the severity and complete scope of the situation." The CCTV evidence clearly showed other prisoners regularly at Mr Ruggiero's cell door, silencing the call bell, banging and kicking at the door (including the wielding of a crutch to hit the door and observation panel), and verbally harassing Mr Ruggiero. The evidence from an SO was that he gave landing officers a clear instruction to intervene; however, it appeared that this did not happen. I was told that the level of officers still in their probationary period has now reduced. I was also told that additional staff training is now in place to address matters such as assertiveness, and that there is also an action plan (albeit I was not shown this). I was also made aware of the 'Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." While some action has been taken, I am not sufficiently reassured that this has addressed the concern and I therefore consider that the risks remain.