Source · Prevention of Future Deaths

Thomas Ruggiero

Ref: 2026-0171 Date: 24 Mar 2026 Coroner: Ian Potter Area: Ian Potter Responses identified: 1 / 1 View PDF

Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.

Date 24 Mar 2026
56-day deadline 19 May 2026
Responses identified 1 of 1
State Custody related deaths

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.

Responses

1 respondent
Oxleas NHS FT
PDF
Received

No AI summary available.

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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Report details

Reference
2026-0171
Date of report
24 March 2026
Coroner
Ian Potter
Coroner area
Ian Potter

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 May 2026.

Sent to

Oxlease NHS Foundation Trust

Part of a series

3 reports
2026-0170 0 responses identified
2026-0172 All responses identified

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