HM Prison Probation Service
Central Government
Action Taken
HM Prison and Probation Service has reissued instructions and introduced quality assurance for cell bell responses, and delivered refresher training on ACCT documents and the 'Code Blue' emergency process. They are also introducing a new 12-month modular training programme and developing learning packages for new prison officers. (AI summary)
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Dear Mr Potter,
Thank you for your two Regulation 28 reports of 23 March 2026 following the inquest into the death of Mr Thomas Daniel Ruggiero at HMP Swaleside on 16 November 2024, one addressed to and the second to the Governor of HMP Swaleside. I am addressing both reports and recipients as the interim Director General of Operations of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Ruggiero’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concern in four areas which include the emergency cell bell system, staff knowledge and understanding in relation to the importance of completing Assessment, Care in Custody and Teamwork (ACCT) documents, staff understanding in relation to the ‘Code Blue’ emergency code process and the number of inexperienced prison officers across the entire prison estate.
Your first concern relates to the emergency cell bell system at HMP Swaleside. I have received assurance from the Governor that following this inquest local instructions were reissued to all operational staff, clearly setting out the expectation that staff must physically check every emergency cell bell that has been activated. Supervising Officers are required to oversee and monitor responses to cell bells, and directly challenge officers where responses to cell bells are not completed in a timely way.
A quality assurance process has been introduced to identify areas of weakness around responding to cell bells, and where any performance related issues are identified these will be escalated through the performance management process.
Your second concern relates to the completion and quality of ACCT documentation, particularly the ACCT Care Plan. I can confirm that the prison is providing rolling weekly refresher training on the ACCT process to operational staff. Additionally, to support staff in the comprehensive completion of ACCT documentation, two Safety Floorwalkers have been introduced. As well as supporting staff in the completion of ACCT documents, the Safety Support Workers will identify areas of additional upskilling and training needs, feeding their findings back to the establishment Safety Team.
HMP Swaleside also plan to introduce scenario-based learning within the ongoing local ACCT refresher training with the aim of reinforcing the importance of the ACCT process, and to improve the overall quality of ACCT record keeping. Furthermore, ongoing partnership working with Oxleas NHS Foundation Trust will strengthen multidisciplinary care and planning for prisoners with complex needs.
Monthly ACCT quality audits are now being carried out locally. Learning identified as part of this audit is disseminated through formal staff briefings and monthly meetings. Where standards are not being met individual accountability measures, including performance management action, will continue to be applied.
HMPPS recognises that for the ACCT process to be effective in supporting a prisoner it must be tailored to their individual needs. Training on suicide and self-harm prevention is provided to all new members of staff with prisoner contact. All staff who undertake key roles relating to risk assessment and case management also receive additional role specific training.
The national ACCT Quality Assurance (QA) process has been firmly embedded at HMP Swaleside, and all open ACCTs are reviewed daily by a Supervising Officer in line with HMPPS national QA guidelines.
Your third concern is about the emergency call code process. I have received assurance from the Governor that written guidance has been reissued to all staff clearly setting out when, how, and by whom a Code Blue must be initiated. Expectations of how a Code Blue response needs to be managed are reinforced through daily briefings and form part of the Night Orderly Officer handover.
Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.
Your fourth concern was about national staffing and staff experience. HMPPS recognise that having sufficient and skilled frontline staff is vital to the safe running of a prison. We are in the early stages of implementing the Enable Programme, which aims to transform prisons over the medium term through a series of workforce changes. This programme is designed to boost training, extend professional development opportunities and invest in our leaders and managers. A key part of the Enable Programme is redesigning the current prison officer foundation training course. This will change the current two-week induction (plus seven
weeks of local training) into a 12-month modular programme to provide more comprehensive development for all new prison officers.
A set of new learning packages is being developed, targeted primarily towards prison officers within their first two years of service. The Reflective Skills Framework (RSF) is a reflective learning intervention developed as part of the Enable programme to build the capability, confidence and professional judgement of front-line prison officers. Its purpose is to provide support in the form of coaching and mentoring through structured reflection on operational practice.
HMPPS continue to take steps to bolster staffing in prisons. Ongoing recruitment campaigns for prison officers are in place at all establishments where there are current or projected vacancies. Enhanced support is provided to those establishments in the most challenging parts of the prison estate.
Central to our efforts to make further improvements to staffing is the Retention Framework. This framework sets out how data, research and insight are used to understand local and national drivers of attrition, guide targeted interventions, and embed retention as a core, ongoing workforce priority. All staff within HMPPS have access to a ‘Career Pathways Framework’ which equips staff with information on career options, as well as learning and development programmes, helping to retain talent within the organisation. HMPPS monitor the reasons staff are leaving through an exit interview process, tracking the drivers of attrition.
Additionally, mentoring and shadowing arrangements are in place for newer members of staff, further supported by a local training and mentoring team.
I hope the measures outlined above taken by HMPPS provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Ruggiero’s death.
Thank you for your two Regulation 28 reports of 23 March 2026 following the inquest into the death of Mr Thomas Daniel Ruggiero at HMP Swaleside on 16 November 2024, one addressed to and the second to the Governor of HMP Swaleside. I am addressing both reports and recipients as the interim Director General of Operations of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Ruggiero’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have expressed concern in four areas which include the emergency cell bell system, staff knowledge and understanding in relation to the importance of completing Assessment, Care in Custody and Teamwork (ACCT) documents, staff understanding in relation to the ‘Code Blue’ emergency code process and the number of inexperienced prison officers across the entire prison estate.
Your first concern relates to the emergency cell bell system at HMP Swaleside. I have received assurance from the Governor that following this inquest local instructions were reissued to all operational staff, clearly setting out the expectation that staff must physically check every emergency cell bell that has been activated. Supervising Officers are required to oversee and monitor responses to cell bells, and directly challenge officers where responses to cell bells are not completed in a timely way.
A quality assurance process has been introduced to identify areas of weakness around responding to cell bells, and where any performance related issues are identified these will be escalated through the performance management process.
Your second concern relates to the completion and quality of ACCT documentation, particularly the ACCT Care Plan. I can confirm that the prison is providing rolling weekly refresher training on the ACCT process to operational staff. Additionally, to support staff in the comprehensive completion of ACCT documentation, two Safety Floorwalkers have been introduced. As well as supporting staff in the completion of ACCT documents, the Safety Support Workers will identify areas of additional upskilling and training needs, feeding their findings back to the establishment Safety Team.
HMP Swaleside also plan to introduce scenario-based learning within the ongoing local ACCT refresher training with the aim of reinforcing the importance of the ACCT process, and to improve the overall quality of ACCT record keeping. Furthermore, ongoing partnership working with Oxleas NHS Foundation Trust will strengthen multidisciplinary care and planning for prisoners with complex needs.
Monthly ACCT quality audits are now being carried out locally. Learning identified as part of this audit is disseminated through formal staff briefings and monthly meetings. Where standards are not being met individual accountability measures, including performance management action, will continue to be applied.
HMPPS recognises that for the ACCT process to be effective in supporting a prisoner it must be tailored to their individual needs. Training on suicide and self-harm prevention is provided to all new members of staff with prisoner contact. All staff who undertake key roles relating to risk assessment and case management also receive additional role specific training.
The national ACCT Quality Assurance (QA) process has been firmly embedded at HMP Swaleside, and all open ACCTs are reviewed daily by a Supervising Officer in line with HMPPS national QA guidelines.
Your third concern is about the emergency call code process. I have received assurance from the Governor that written guidance has been reissued to all staff clearly setting out when, how, and by whom a Code Blue must be initiated. Expectations of how a Code Blue response needs to be managed are reinforced through daily briefings and form part of the Night Orderly Officer handover.
Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.
Your fourth concern was about national staffing and staff experience. HMPPS recognise that having sufficient and skilled frontline staff is vital to the safe running of a prison. We are in the early stages of implementing the Enable Programme, which aims to transform prisons over the medium term through a series of workforce changes. This programme is designed to boost training, extend professional development opportunities and invest in our leaders and managers. A key part of the Enable Programme is redesigning the current prison officer foundation training course. This will change the current two-week induction (plus seven
weeks of local training) into a 12-month modular programme to provide more comprehensive development for all new prison officers.
A set of new learning packages is being developed, targeted primarily towards prison officers within their first two years of service. The Reflective Skills Framework (RSF) is a reflective learning intervention developed as part of the Enable programme to build the capability, confidence and professional judgement of front-line prison officers. Its purpose is to provide support in the form of coaching and mentoring through structured reflection on operational practice.
HMPPS continue to take steps to bolster staffing in prisons. Ongoing recruitment campaigns for prison officers are in place at all establishments where there are current or projected vacancies. Enhanced support is provided to those establishments in the most challenging parts of the prison estate.
Central to our efforts to make further improvements to staffing is the Retention Framework. This framework sets out how data, research and insight are used to understand local and national drivers of attrition, guide targeted interventions, and embed retention as a core, ongoing workforce priority. All staff within HMPPS have access to a ‘Career Pathways Framework’ which equips staff with information on career options, as well as learning and development programmes, helping to retain talent within the organisation. HMPPS monitor the reasons staff are leaving through an exit interview process, tracking the drivers of attrition.
Additionally, mentoring and shadowing arrangements are in place for newer members of staff, further supported by a local training and mentoring team.
I hope the measures outlined above taken by HMPPS provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Ruggiero’s death.