Thomas Ruggiero
PFD Report
No Identified Response
Ref: 2026-0171
Coroner's Concerns (AI summary)
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
View full coroner's concerns
The MATTER OF CONCERN is as follows. - (1) There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews. In this case, there were numerous instances that this was not met. While I heard evidence of some improvement, it was accepted that there were ongoing issues with securing the attendance of the mental health team (where required) at ACCT reviews. I was insufficiently reassured that the matter has been addressed and I consider that there is ongoing risk to particularly vulnerable prisoners for whom the ACCT processes should act as a safety-net and protective factor.
Part of a Series
3 separate reports were issued from this inquest, each sent to different organisations.
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2026-0170
Sent to: Department for Prison, Probation and Reducing Reoffending;No responses yet
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2026-0172
Sent to: HMP SwalesideNo responses yet
This report (2026-0171) is shown above.
Sent To
- Oxlease NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
19 May 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18 November 2024 an investigation into the death of Thomas Daniel RUGGIERO was commenced. The investigation concluded at the end of the inquest heard by me and before a jury between 9 - 20 March 2026. The conclusion of the inquest was: Mr Ruggiero died by ligaturing himself in circumstances where his intention could not be ascertained. 1a Hanging 1b 1c 1d
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.