Thomas Ruggiero

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Independent investigation into
the death of Mr Thomas Ruggiero,
a prisoner at HMP Swaleside,
on 16 November 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Thomas Ruggiero died on 16 November 2024, after he was found hanging in his cell at
HMP Swaleside. He was 39 years old. I offer my condolences to Mr Ruggiero’s family and
friends.
Mr Ruggiero was a vulnerable man who struggled with mental illness and often used illicit
drugs. Prison staff, substance misuse practitioners and mental health staff took action to
support him. Mr Ruggiero spent several periods in the prison’s inpatient wing. He struggled
to maintain stability when he returned to a general wing, often self-harmed, and this led to
cycles of readmission. There was not always continuity of care and there was a lack of
professional curiosity about what drove his self-harm.
The clinical reviewer concluded that the care Mr Ruggiero received was not equivalent to
that which he could have expected to receive in the community.
Mr Ruggiero’s death was the ninth self-inflicted death in three years at Swaleside.
Investigations into five of those deaths identified deficiencies in the way the prison
managed suicide and self-harm prevention procedures, known as ACCT. I am
disappointed that some aspects of ACCT management remain problematic. The Executive
Director of the Long Term and High Security Estate and the Governor of Swaleside will
want to ensure effective action is taken to reduce the likelihood of further self-inflicted
deaths at Swaleside.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 20
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Summary
Events
1. On 16 July 2020, Mr Thomas Ruggiero was remanded into custody at HMP
Wandsworth, charged with assault. He had been in prison before. In September, Mr
Ruggiero was sentenced to an extended determinate sentence of eight years
imprisonment, with an extended licence period of 18 months.
2. Mr Ruggiero had drug-induced psychosis, attention deficit hyperactivity disorder
and emotionally unstable personality disorder. He had a history of chronic alcohol
and drug misuse in the community and prison. He had a history of self-harm in
prison. In September 2024, he said that he heard voices telling him to cut himself
and that he had strangled himself to “cut off circulation around his neck and bring
himself into a medicated depression” but not to end his life. Mr Ruggiero did not
always comply with his medication.
3. Mr Ruggiero frequently used psychoactive substances (PS, also known as spice) in
prison. This led to a deterioration in his mental health, compounded by him not
taking his prescribed medications. He was admitted to the prison’s inpatient
department (IPD) six times due to his deteriorating mental health. During
admissions, Mr Ruggiero started taking his medication, avoided illicit drug use and
stabilised. Mr Ruggiero also spent two periods in segregation after he set fire to his
cell and assaulted another prisoner. He said he used periods in the IPD and
segregation unit to detox from drugs.
4. On the occasions Mr Ruggiero returned to a standard wing, he said he found it hard
not to use drugs. This led to a deterioration in his mental health and an increase in
self-harm which inevitably resulted in him being readmitted to the IPD. Mr Ruggiero
experienced this cycle many times.
5. Mr Ruggiero was monitored under suicide and self-harm prevention procedures
(known as ACCT) thirteen times due to self-harm and telling staff he would kill
himself. He was supported by ACCT procedures in October 2024 after he made
cuts to his arms and legs. On 8 November, Mr Ruggiero was placed under constant
supervision after he cut his genitals and said he was going to kill himself. He was
moved to the IPD.
6. On 14 November, Mr Ruggiero was discharged and returned to B Wing. Constant
supervision stopped and staff were required to check him once an hour. On his
return, staff thought Mr Ruggiero looked and presented well.
7. On the morning of 16 November, Mr Ruggiero damaged items in his cell and told
staff his demons had returned. He demanded to be taken back to the IPD. At
9.50am, staff found Mr Ruggiero hanging in his cell after prisoners and officers
alerted them. Nurses, prison staff and paramedics resuscitated him, but Mr
Ruggiero suffered a cardiac arrest as paramedics moved him to the air ambulance
and paramedics pronounced life extinct at 1.43pm in the grounds of the prison.
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Findings
8. Mr Ruggiero was a vulnerable man with complex needs. Prison staff took positive
actions to support him during crisis periods. They supported him under suicide and
self-harm prevention procedures (known as ACCT) which included periods under
constant supervision. Wing staff liaised well with healthcare staff to ensure Mr
Ruggiero received support through admission to the IPD.
9. ACCT measures were started promptly on 27 October and initial assessments were
timely. ACCT reviews took place regularly. Records indicate these were not always
multidisciplinary but healthcare staff had been consulted. Poor record keeping
undermined written reviews. Mr Ruggiero’s care plan was blank and did not reflect
changes to his risk, protective factors and actions taken to support him. There was
evidence of staff putting support in place but this was not recorded. Staff did not
always see the value in completing care plans. Constant supervision was
reasonably stopped on 14 November. However, the frequency of checks was
reduced too quickly to one per hour which did not reflect Mr Ruggiero’s risk. There
was inadequate exploration about why Mr Ruggiero harmed himself.
10. The clinical reviewer found that Mr Ruggiero moved from service to service in a
reactive manner and there was a lack of professional curiosity about the correlation
between his trauma and mental state. Admissions to the IPD or being held in the
segregation unit enabled Mr Ruggiero to stop using drugs, take his medication and
stabilise his mental health. However, he quickly relapsed into illicit drug use on
discharge, and this led to frequent crisis periods and repetitive cycle of readmission
to the IPD.
11. Prison staff radioed an incorrect emergency code when they found Mr Ruggiero
hanging in his cell. The control room log was unclear about when an ambulance
was called and it is not possible to say if there was a delay.
Recommendations
The Executive Director for the Long Term and High Security Estate and the
Governor should formulate a robust plan, with sufficient oversight and
auditable measures to ensure that prison staff manage prisoners at risk of
suicide and self-harm in line with the Prison Safety Policy Framework, and in
particular, they should:
• hold and accurately record multidisciplinary reviews, with healthcare
staff and other relevant staff providing detailed input if they are unable
to attend;
• set a frequency of observations appropriate to the level of risk; and
• ensure care plans are fully completed, person-centred and responsive
to risk.
The Head of Healthcare should ensure that:
• healthcare staff are involved in all ACCT reviews while a prisoner is in
the IPD; and
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• an audit of treatment plans is undertaken to ensure that they are clearly
documented in the clinical records and reviewed.
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The Investigation Process
12. HMPPS notified us of Mr Ruggiero’s death on 16 November 2024.
13. The investigator issued notices to staff and prisoners at HMP Swaleside informing
them of the investigation and asking anyone with relevant information to contact
her. One prisoner responded and he was interviewed in January 2025.
14. The investigator visited HMP Swaleside on 20 November 2024. She obtained
copies of relevant extracts from Mr Ruggiero’s prison and medical records. She
watched body-worn camera footage and CCTV footage from 16 November 2024
and obtained information from the South East Coast Ambulance Service.
15. The investigator interviewed four members of staff at Swaleside on 8 January 2025.
She interviewed six members of staff remotely by Microsoft Teams in December
2024 and January 2025.
16. NHS England commissioned a clinical reviewer to review Mr Ruggiero’s clinical
care at the prison. The clinical reviewer and the investigator jointly interviewed
healthcare staff.
17. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
18. The Ombudsman’s office contacted Mr Ruggiero’s mother and sister to explain the
investigation and to ask if they had any matters they wanted us to consider.
19. Mr Ruggiero’s mother wanted us to know that she thought her son’s mental health
was poor. She believed he was refused vital medication for a long time and when it
was prescribed, he was unable to take it responsibly. Mr Ruggiero’s mother asked
some questions which we have addressed in separate correspondence. She also
asked the following questions which we have addressed in this report:
• Why did nobody intervene to help Mr Ruggiero on the morning of 16
November?
• Where was Mr Ruggiero located? Mr Ruggiero’s mother said she was
concerned he was moved to a general wing from a wing for vulnerable
prisoners.
20. Mr Ruggiero’s sister said that she shared her mother’s concerns. She had one
question which we have addressed in separate correspondence and the following
questions which we have addressed in this report:
• What mental health support did Mr Ruggiero receive?
• For how long was Mr Ruggiero left in his cell before he was found hanging?
• Why did Mr Ruggiero kill himself?
• Did Mr Ruggiero have access to and/or did he access illicit drugs in prison?
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Mr Ruggiero did not leave a note in his cell. It is very difficult to establish with
certainty a person’s reasons for ending their life.
21. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is an additional
annex to this report.
22. Mr Ruggiero’s mother and sister received a copy of the draft report. The solicitor
representing them wrote to us pointing out some factual inaccuracies. The report
has been amended accordingly. They also raised a number of questions that do
not impact on the factual accuracy of this report. We have provided clarification by
way of separate correspondence to the solicitor.
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Background Information
HMP Swaleside
23. HMP Swaleside, on the Isle of Sheppey, is part of the long-term high security
estate, predominantly holding prisoners judged to be high risk and those serving
long As. Oxleas NHS Foundation Trust provides physical and mental healthcare
services, including 24-hour nursing cover. Change, Grow, Live (CGL) provides
substance misuse services.
HM Inspectorate of Prisons
24. The most recent inspection of Swaleside was in September 2023. Inspectors
reported that safety remained a concern. They noted that Swaleside had made real
efforts to improve despite the challenges faced by the restricted regime caused by
the difficulties recruiting staff.
25. An independent review of progress was carried out in August 2024. In the
subsequent report, inspectors noted that the recorded rate of self-harm and the
number of individuals involved had increased over the previous 11 months. There
was compelling evidence that staff did not always complete the required checks on
prisoners at risk of suicide and self-harm and inspectors were not confident that
records they had examined were accurate. Some of the care plans in the ACCT
documentation were months out of date and did not reflect the prisoners’ current
needs. None of the plans focused on getting prisoners into activity and sometimes
the support was repeatedly stopped and restarted without addressing the
underlying issues.
26. Illicit drugs were even more readily available than they had been during the
previous full inspection. Inspectors also noted that there had been a substantial
change in the way drugs and other illicit items were being supplied and
sophisticated drones were used to deliver packages. This undermined safety and
stability in the prison and the use of drugs underpinned the lack of progress in many
of the concerns set out in their report.
27. Inspectors reported that they were impressed that the acute shortage of officers,
which they noted in their last report, had been addressed through proactive
recruitment. However, at the time of the follow-up inspection, just over half the
officer group had less than a year in service. This level of inexperience inevitably
led to a continuing lack of confidence and assertiveness in the management of
prisoners.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 30 April 2024, the IMB reported
that they remained concerned about the mental health of prisoners who had
suffered long-term lockdown due to the restricted regime. This was evidenced by
the number of opened ACCT documents, self-harm cases and violent incidents.
The IMB said that the first indications from the recent improvement in regime were
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positive. However, the need for increased psychology and psychiatric services still
needed to be assessed.
Previous deaths at HMP Swaleside
29. Mr Ruggiero was the twenty-second prisoner to die at Swaleside since November
2021. Of the previous deaths, eight were self-inflicted, 10 were due to natural
causes, two were drug-related and one was unascertained. Our investigations into
five of the previous self-inflicted deaths found deficiencies in the way the prison
managed suicide and self-harm procedures (ACCT). Since Mr Ruggiero’s death up
until May 2025, two prisoners have died, one from natural causes and the other
from an unknown cause. Both deaths remain under investigation.
Assessment, Care in Custody and Teamwork
30. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service case
management approach used to support prisoners at risk of suicide or self-harm.
The purpose of ACCT is to try to determine the level of risk, how to reduce the risk
and how best to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur. As part
of the process, a support plan, also known as an action plan, should be put in place.
The ACCT plan should not be closed until all the actions of the risk reduction plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. The Prison Safety
Policy Framework sets out how staff should operate ACCT procedures.
Psychoactive substances
31. Psychoactive substances (PS) is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazenes) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
32. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
Background
33. On 16 July 2020, Mr Thomas Ruggiero was remanded into custody at HMP
Wandsworth, charged with assault. He had been in prison before. On 14
September, Mr Ruggiero was sentenced to an extended determinate sentence of
eight years imprisonment, with an 18-month extended licence period. In November
2020, June 2021 and February 2022, Mr Ruggiero was sentenced to further periods
of imprisonment for assaulting prison officers.
34. Mr Ruggiero had drug-induced psychosis, attention deficit hyperactivity disorder
and emotionally unstable personality disorder. He had a history of chronic alcohol
and drug misuse and a history of self-harm.
35. Mr Ruggiero spent time at various prisons and had periods where he was monitored
under suicide and self-harm prevention procedures, known as ACCT. Mr Ruggiero’s
mental health was unstable, and he did not always take his prescribed medications
(antipsychotic and mood stabiliser). This was compounded by his use of illicit
substances, typically PS. He spent two periods in the inpatient healthcare unit at
HMP High Down in 2021.
HMP Swaleside
36. On 21 November 2022, Mr Ruggiero was transferred to HMP Swaleside and was
referred to the mental health team when he arrived. Nurse F, a mental health nurse,
noted Mr Ruggiero had a history of making but not using ligatures. Mr Ruggiero was
discussed at the mental health team meeting, where they concluded he would not
be taken onto their caseload because his mental health needs could be met by the
primary care team. Actions were set to refer him to the substance misuse team and
psychology.
37. Between January and July 2023, Mr Ruggiero spent two periods in the inpatient
department (IPD) as he was not complying with his medication, his mental health
was deteriorating and he was cutting his eyes and penis. Referrals were again
made to the mental health team and he was kept under constant supervision on an
ACCT. On discharge from the IPD, Mr Ruggiero returned to a standard wing and
was soon found under the influence of PS.
38. Mr Ruggiero asked for support from the substance misuse service and was
discussed at the team’s complex case meeting. Ms A saw him in February 2023
and gave him harm reduction advice. Mr Ruggiero said he no longer wanted to
engage with the service. Following this, Mr Ruggiero and prison staff made further
substance misuse referrals for him. Ms A saw Mr Ruggiero and tried to assess him
five times. Due to his mental state and not engaging, he was discharged from the
service.
39. In August, Mr Ruggiero set fire to his cell and spent two weeks in the segregation
unit (where prisoners are kept separate from the general population) before
returning to a general wing in September. Mr A from the Swaleside Outreach
Service (SOS) assessed Mr Ruggiero (SOS is a Swaleside initiative bringing
together prison officers, mental health social workers and psychologists who work
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with prisoners whose behaviour is challenging, violent or disruptive). Mr Ruggiero
attended SOS hub and was accepted onto the psychologically-informed planned
environment (known as the PIPE Unit) at Swaleside. This move did not happen due
to Mr Ruggiero’s deteriorating mental health and his further admission to the IPD.
40. Mr Ruggiero continued to be supported by SOS and ACCT monitoring in early
2024, including under constant supervision in the IPD in March after he cut his
penis. In May, Mr Ruggiero met Mr B, a SOS worker, to complete an application to
the Pre-PIPE Unit at HMP Long Lartin. Mr Ruggiero said he felt more settled.
41. Mr Ruggiero continued to be supported by ACCT due to cutting his penis which
required hospital treatment. He told staff he had been using PS. He returned to B
Wing on 23 March and said he was fine.
42. In June, Mr Ruggiero damaged items in his cell several times and told staff he was
going to kill himself. His ACCT observations were increased to constant
supervision. Following his return to B Wing, SOS continued to see Mr Ruggiero
regularly.
43. In July, Ms A from the substance misuse service assessed Mr Ruggiero (the
medical records do not document a new referral). He told her he did not want to
engage and asked her to come back the next day. When Ms A returned, Mr
Ruggiero told her he did not need or want to engage with the service but would
contact them in six months’ time.
44. In August, Mr Ruggiero returned to the IPD for two weeks due to a decline in his
mental health and use of PS.
45. On 1 September, he cut his penis and told staff he would continue to do so unless
he was moved back to a general wing. The following day, he went into another
prisoner’s cell and began destroying his property. He had opened cuts on his hand
and penis and splashed blood around the cell. Officer A recorded that Mr Ruggiero
had smashed items in his cell, destroying the cupboard, table and half his bed. He
noted Mr Ruggiero was making mixed demands of wanting to return to the wing but,
at other times, asking to be under constant supervision.
46. On 4 September Mr Ruggiero was discussed at the IPD ward round and his
medication was reviewed. The team reflected that he continued to self-harm by
cutting his penis and had destroyed two cells. Mr Ruggiero continued to be
supported by ACCT procedures and SOS. After a period of settled behaviour, he
was discharged from the IPD and returned to B Wing on 12 September.
47. At around 9.00pm on 15 September, Officer B asked Supervising Officer (SO) A to
see Mr Ruggiero as he was hiding under his bed and was not responding during
ACCT checks. When SO A unlocked Mr Ruggiero’s cell, Mr Ruggiero ran towards
him, threatening violence. SO A locked the door and spoke to Mr Ruggiero through
it. Mr Ruggiero told him he was not in crisis and liked sleeping under the bed so
they “could not use the remote control on him”. SO A referred him back to the
mental health team.
48. On 16 September, Mr Ruggiero attended his ACCT review with SO B and Nurse A,
a mental health nurse. Mr Ruggiero told them he had been smoking PS since his
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discharge from the IPD and felt “in a manic phase”. He said he had been tying
ligatures to get a “drop kick”. He said they were not suicide attempts but he got a
“drop” when he cut off circulation around his neck and was bringing himself down
into a “medicated depression”. Nurse A spoke to him about the risks of this,
including that he could kill himself without intending to. She assessed he lacked
insight into the risks. The review concluded that Mr Ruggiero should return to
constant supervision.
49. Nurse A and SO B spoke to Dr A, a psychiatrist, who then saw Mr Ruggiero. Mr
Ruggiero told him he had smoked a mint vape and felt like he wanted to get “relief
from the throat so is using the noose”. Dr A advised Mr Ruggiero needed to be
moved back to the IPD under constant supervision.
50. On 20 September, Mr Ruggiero returned to B Wing. Constant supervision stopped
and he was placed on hourly checks. On 27 September, SO C chaired an ACCT
review with Nurse A. Mr Ruggiero said his psychotic symptoms had gone and he
felt much better. He denied thoughts of suicide and self-harm. However, Nurse A
noted he presented “an ongoing chronic risk” of suicide and self-harm in the context
of his history and mental health symptoms. She identified PS use as a trigger for
deterioration in his mental health. The review concluded the ACCT could be closed.
51. The following morning, Mr C from SOS spoke to Mr Ruggiero on B Wing. Mr
Ruggiero told him he was doing well, keeping himself busy, helping on the wing and
cleaning the exercise yard. Mr C noted he appeared happy and engaged. Mr
Ruggiero said he did not need anything from SOS. Mr C reminded him he could
send a message to SOS if he needed support and he remained on their caseload.
52. In October, SOS saw Mr Ruggiero weekly. On 2 October, Mr Ruggiero told Mr D
from SOS that he was still on track and felt good. He said he did not need anything
from the team but would reach out if anything changed. On 10 October, Mr
Ruggiero spoke to Mr C and said he was fine and waiting for his assessment with
Long Lartin for the Pre-PIPE Unit.
53. On 17 October, Mr B from SOS spoke to Mr Ruggiero through his cell door. Mr
Ruggiero told him he was staying in his cell as he was fed up with other prisoners
and wanted to move to another wing. He did not give any detail and said he wanted
to be settled as he wanted to move to the unit at Long Lartin.
54. During the first half of October, Mr Ruggiero maintained regular telephone contact
with his mother. He talked positively about a possible move to the Pre-PIPE Unit at
Long Latin and that she could visit him there as it would be closer to home. He said
he did not think he would be granted parole at his next review. His mother
encouraged him to continue working towards it.
55. At 7.11am on 21 October, Officer C recorded that Mr Ruggiero had been wailing
and shouting out of his window. Mr Ruggiero asked Officer C to contact the mental
health team for him, which Officer C subsequently did by email.
56. At 10.30am, Nurse A spoke to Mr Ruggiero on B Wing. She noted he was chaotic
and manic, jumping from topic to topic. She noted she was informed he had been
taking PS (It is unclear whether Mr Ruggiero told her this). Mr Ruggiero asked to
see Dr A as he felt manic and wanted his medication reviewed. Mr Ruggiero denied
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any thoughts of suicide or self-harm. However, Nurse A assessed he posed an
ongoing chronic risk of suicide and self-harm given his history and mental health.
She noted a plan for a potential psychiatric review, he would remain on her
caseload, he should alert staff if he was worried about his safety and staff should
consider opening an ACCT (including considering constant supervision) if his risk
increased.
57. At 11.14am on 25 October, Mr D from SOS spoke to Mr Ruggiero who told him he
needed to move to C Wing. Mr D thought this was because other prisoners had
been challenging him about his behaviour as he had kept them up over the past few
nights, banging in his cell. He told Mr Ruggiero he would look into this.
58. At around 5.20am on 27 October, Officer Support Grade (OSG) A recorded in Mr
Ruggiero’s electronic prison record that between 4.50am and 5.25am, Mr Ruggiero
pressed his emergency cell bell multiple times, asking to be moved to a “safe plastic
cell”. He said he was hearing voices telling him to do things he did not want to do.
Officer A told him he would speak to the duty nurse and recorded he had contacted
a nurse by radio.
59. At around 6.04am, staff radioed a medical emergency code red after Mr Ruggiero
made cuts to his arm. He told staff demons made him do it, he would continue to do
it and needed constant supervision. Nurse B attended and treated Mr Ruggiero’s
wounds, but Mr Ruggiero would not let him assess him. The nurse noted that Mr
Ruggiero looked dishevelled, and his cell was covered in blood. Nurse B
recommended that staff should open an ACCT, with a minimum of three checks an
hour. He sent an urgent request for the mental health team to see Mr Ruggiero and
for the doctor to review his medication.
60. Officer D began ACCT procedures and recorded that Mr Ruggiero seemed erratic
and, at points, appeared to think someone else was standing next to him, talking to
them.
61. Custodial Manager (CM) A completed an immediate action plan for Mr Ruggiero at
around 6.30am. He recorded that Mr Ruggiero was to remain in his own cell and
that staff should check him three times per hour as he was threatening to continue
harming himself. He noted that Mr Ruggiero told him he had not been taking his
antipsychotic medication.
62. Mr Ruggiero’s medical records refer to a further emergency code blue (which
indicates a prisoner is unconscious or having difficulty breathing) at 7.11am. This is
not documented anywhere else and no details are known about it.
63. At around 9.35am, an officer checked on Mr Ruggiero in line with his ACCT
observations. They saw he had made cuts to his arm and legs and radioed an
emergency code red (indicating blood loss). Mr E, a paramedic working at
Swaleside, attended. When he arrived, he noticed drying blood on the cell floor. Mr
Ruggiero said his mind was telling him to do things to harm himself and he was
trying to mitigate this by making small injuries to himself. He said he was being
bullied on the wing and he felt the IPD would help. Mr E spoke to SO B. They
agreed that as this was the third code red incident in four hours for Mr Ruggiero and
he was repeatedly making statements about harming himself further, he needed to
be placed under constant supervision.
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64. At around 11.10am, Mr Ruggiero was moved to the IPD but he was not placed
under constant supervision and the frequency of ACCT checks remained
unchanged. Nurse C recorded in Mr Ruggiero’s medical records that he was
aggressive, restless and agitated. Mr Ruggiero told her he was going to set fire to
his cell and was under attack by different people. He did not allow staff to assess
him and walked away, saying he was too busy. He denied thoughts of suicide or
self-harm.
65. At around 3.00pm, Ms B from the safer custody team began Mr Ruggiero’s ACCT
assessment and recorded information she had obtained from other departments
about him. Healthcare staff advised her that Mr Ruggiero was taking his medication
as prescribed, but wing staff said Mr Ruggiero had been behaving erratically.
66. At around 3.40pm, Ms B completed Mr Ruggiero’s ACCT assessment. She
recorded she was unable to speak to him for long as he wanted to be left alone. Mr
Ruggiero told her he had a demon attached to him who told him to hurt himself and
when he did so, the demon stopped talking for a bit. He said he did not want to die
but it was inevitable he would one day. Ms B documented that she was unable to
complete the sections in the ACCT document on sources of support because of Mr
Ruggiero’s mental capacity. She reflected he was to remain in the IPD. No care
plan actions were identified.
67. At around 10.00am the following day, SO B, the ACCT case manager, tried to
speak to Mr Ruggiero for his first review. Mr Ruggiero refused to engage. SO B
spoke to healthcare staff who said that Mr Ruggiero had been up all night shouting
and was clearly still unwell. The SO set a review date of 30 October to allow Mr
Ruggiero a few days to settle and be more able to engage. SO B reduced Mr
Ruggiero’s observation levels to two per hour but did not update the care plan.
68. At 4.43pm, Mr F from SOS asked Mr Ruggiero if he wanted to attend a yoga
session in the day centre. Mr Ruggiero said he did not want to as he was not in the
right head space. He asked about his assessment for the Pre-PIPE Unit at Long
Lartin as it was playing on his mind.
69. At 8.30am on 30 October, Mr Ruggiero made superficial cuts to his wrist. He told
healthcare staff that the voices were “becoming external and more demonic".
70. At 10.44am on 2 November, Mr Ruggiero phoned his mother. He told her he was in
the IPD and was looking forward to his pre-PIPE assessment. Mr Ruggiero said he
was getting good support from SOS and that felt like “a light at the end of a tunnel”.
He told her he intended to accept his antipsychotic medication by depot injection as
he was not very good at taking tablets (there is no evidence in Mr Ruggiero’s
medical record that staff had discussed the option of receiving his medication by
injection). Mr Ruggiero told his mother he was looking forward to Christmas and
was feeling quite optimistic.
71. At around 3.00am on 4 November, Nurse D observed that Mr Ruggiero had woken
up and was throwing things around his cell.
72. At 1.11pm on 5 November, Mr B from SOS spoke to Mr Ruggiero in the IPD. Mr B
observed Mr Ruggiero’s cell was clean and tidy and his mood seemed positive. Mr
Ruggiero talked about his assessment for the Pre-PIPE Unit at Long Lartin and
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asked for advice about what questions he may be asked. Mr B told him he would
book a session for him to attend the day centre so they could discuss it. Mr
Ruggiero thanked him.
73. At 4.24pm on 6 November, Dr A recorded he had seen Mr Ruggiero during his ward
round and he had seemed calm. He assessed that Mr Ruggiero could be
discharged from the IPD as he was no longer acutely depressed, psychotic or
suicidal. He asked the mental health team to provide follow-up support.
74. At 5.18am the following morning, Nurse E recorded that Mr Ruggiero had an
unsettled night, he had been awake since 3.00am and appeared to have
conversations with himself. Later that afternoon, he was placed on report pending a
disciplinary hearing after he damaged his television and television cabinet.
75. At 1.10pm, Mr Ruggiero asked Ms A for support from her service. Ms A told him
someone would see him in a week.
76. Mr Ruggiero was discharged from the IPD and returned to B Wing at 5.16pm that
afternoon. He remained on an ACCT with observation intervals set at one per hour.
Healthcare staff referred him for structured psychosocial intervention.
77. At 4.05pm on 8 November, Mr Ruggiero made cuts to his penis, testicles and arms.
Nurses attended and treated his wounds. Nurse F, a mental health nurse who was
the duty worker for the mental health team, also responded. Mr Ruggiero told staff
he was going to kill himself. At around 5.00pm, SO B conducted an urgent ACCT
review and Mr Ruggiero was placed under constant supervision.
78. Nurse F emailed the IPD’s Clinical Nurse Manager, Mr G. She said she saw Mr
Ruggiero in his cell screaming and shouting things that did not make sense. He told
her he had tried to cut his penis and testicles off and told SO B he wanted to end
his life. She thought he was in a state of psychosis or crisis.
79. Mr G told Nurse F that Dr A had seen Mr Ruggiero on his ward round on 6
November. Dr A had not assessed that he presented with acute depression,
psychosis or at particular risk of suicide. Mr G said it was reported that Mr Ruggiero
used spice when he returned to the wing. He felt the predominate issue was drugs
and the IPD could not offer a permanent solution to his problem.
80. On 9 November, Mr Ruggiero’s disciplinary hearing was adjourned as he was unfit
to attend.
81. At around 11.00am on 10 November, SO D conducted an ACCT review with SO E,
Ms B and Officer E from the safer custody team. Healthcare staff did not attend. Mr
Ruggiero shouted that he had a heart condition and did not want to speak to staff.
The team concluded that he needed to remain under constant supervision and
scheduled a review for the following day. He returned to the IPD.
82. At 11.08am on 11 November, Dr B from the mental health team met Mr Ruggiero
for a follow-up appointment. Mr Ruggiero told him he was offered PS almost
immediately on his return to B Wing on 8 November which he accepted and took.
He said he had been asked to hold “hooch” (prison slang for alcohol) for other
prisoners and when he declined, he became under threat. As a result, he cut
himself. Mr Ruggiero said he became stable when he was either moved to the IPD
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or the segregation unit. He said he treated them as a detoxification period before
using illicit substances again when he returned to general location. Mr Ruggiero
denied thoughts of suicide or self-harm. He was adamant he did not want to return
to B Wing as he felt under threat from other prisoners there (there is no recorded
evidence that staff discussed moving him to any other wings).
83. At 8.00am on the morning of 12 November, Mr Ruggiero was unlocked and
prompted to attend the medication hatch to collect his medication. He did not attend
and instead mixed with other prisoners.
84. At around 10.35am, an officer saw Mr Ruggiero tying a ligature made from his
blanket around the hinge of his cell door. They radioed an emergency code blue
and Mr E attended. Mr Ruggiero tried to tie the blanket around his neck but officers
cut and removed it. Mr Ruggiero said he was upset as he had not been taken for his
medication yet that morning.
85. At 1.51pm on 13 November, Dr B recorded that Mr Ruggerio had been reviewed at
the mental health team’s multidisciplinary meeting. The team discussed possibly
discharging Mr Ruggiero from their caseload. Dr A said he felt Mr Ruggiero needed
further support before being discharged.
86. At around 10.00am the following day, SO C conducted a multidisciplinary ACCT
review with Nurse A, Ms B from the safer custody team and Officer F. Mr Ruggiero
attended. The team observed that Mr Ruggiero looked clean and well presented. Mr
Ruggerio said he had been occupying his time by finding his spiritual/religious
beliefs and working on himself as a person. He told the team he had not had any
thoughts of self-harm over the past few days and knew how to reach out to staff if
he needed help. The team noted that Mr Ruggiero had a positive family support
network and was waiting to be assessed for the Pre-PIPE Unit at Long Lartin. Mr
Ruggiero said he had planned to keep himself occupied and did not want to slip
back into his old habits of using substances. He said he had re-engaged with the
substance misuse team and felt it was going well. The team concluded that Mr
Ruggiero no longer needed constant supervision. His ACCT remained open, with
observations reduced to one per hour.
87. Nurse A recorded in Mr Ruggiero’s medical records that Mr Ruggiero said he felt
much better and was no longer in crisis. He acknowledged his drug use led to a
deterioration in his mental health which then led to him harming himself. Mr
Ruggiero said he had had time to reflect. He wanted to engage with the substance
misuse team as he wanted to live a healthy life and not use illicit substances. Mr
Ruggiero said he was keen to engage with the assessment for the Pre-PIPE Unit
and to move to Long Lartin, if accepted. Mr Ruggiero said he had not heard voices
for some time. He denied thoughts of suicide or self-harm, engaged in safety
planning and agreed to tell staff if he felt distressed or had any concerns. Nurse A
noted the plan was for Mr Ruggiero to remain on her caseload. She emailed the
substance misuse team and asked them to check in with Mr Ruggiero.
36. At around 1.00pm, Mr C and SO A spoke to Mr Ruggiero. They noted he seemed in
good spirits and did not display as someone in crisis. Mr Ruggiero told them he
wanted to come off constant supervision and return to B Wing, with the intention of
moving to C Wing in the future. He asked about his assessment with the Pre-PIPE
Unit at HMP Long Lartin.
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37. Mr Ruggiero returned to B wing that afternoon. Officer G and Officer H were
working on B Wing. They told the investigator that Mr Ruggiero was smiling, and
they noticed he had a new haircut. He asked them for materials to clean his cell. He
told them he was fine.
38. At 4.30pm, Mr Ruggiero telephoned his mother. He told her he had returned to B
Wing and was settling down for Christmas. He said he was due to have an
assessment with staff from Long Lartin.
39. At 2.18pm on 15 November, Ms A completed an initial substance misuse
assessment with Mr Ruggiero. She recorded that Mr Ruggiero engaged well and
was interested in engaging with the service. She noted this would be raised at the
referral meeting. She gave Mr Ruggiero harm reduction advice.
Events of 16 November
40. The investigator watched CCTV and body worn video camera (BWVC) footage,
listened to radio traffic and obtained prison statements and South East Coast
Ambulance Service records. The following account is taken from all those sources.
41. Officer B monitored Mr Ruggiero once an hour overnight in line with his ACCT
observation requirements.
42. At some time between 5.00am and 5.30am, Prisoner A, a prisoner in the cell next to
Mr Ruggiero’s, woke up as he heard Mr Ruggiero shouting and banging his door.
He told the investigator that he heard Mr Ruggiero shouting that the demons were
back, and he needed his medication. Prisoner A heard Officer B tell him he could
not unlock him for medication yet.
43. SO C, Officer G, Officer I, Officer H and Officer J arrived for their shifts and
attended a handover and briefing in the B Wing office at around 8.30am. Officer G
remembered being told Mr Ruggiero was on an ACCT. Officer I and Officer H told
the investigator that they could not recall whether Mr Ruggiero was mentioned.
Officer J was assigned to look after Mr Ruggiero’s spur.
88. Officer G was assigned to unlocking prisoners for exercise and supervising
prisoners on the exercise yard. He told the investigator that he heard Mr Ruggiero
banging on his cell door and shouting that he needed his medication.
89. At around 8.45am, Officer J heard loud bangs from Mr Ruggiero’s cell and noticed a
prisoner standing outside. He went to Mr Ruggiero’s cell and saw the observation
panel was damaged and could see Mr Ruggiero inside his cell, breaking furniture.
He told the investigator that Mr Ruggiero was shouting and screaming about
medication, and that he wanted to go back to the IPD. Officer J said other prisoners
were shouting at him through his door. He thought they were angry as Mr Ruggiero
had disturbed them overnight.
90. Between 8.04am and 8.50am that morning, Mr Ruggiero pressed his emergency
cell bell five times. Officers answered all the calls within three minutes. Officer J
spoke to Mr Ruggiero and told him that he could not unlock him yet as prisoners
who were self-isolating were unlocked but he would speak to nurses on the wing to
ensure he got his medication. He told Mr Ruggiero that he would get his medication
at around 9.00am when those prisoners were back in their cells.
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91. At around 9.04am, Officer J, Officer I and Officer G unlocked Mr Ruggiero’s cell and
walked with him to the medication hatch. They all noticed that he was walking
quickly which he never normally did, but he seemed calm. At 9.05am, Mr Ruggiero
was locked back in his cell.
92. Officer J spoke to the nurse dispensing medication afterwards and asked why Mr
Ruggiero had been discharged from the IPD as he thought he should still be there.
He said the nurse told him Mr Ruggiero had been deemed fit to return to the wing.
Officer I told the investigator that he heard Officer J speaking to a nurse on the
wing, asking why Mr Ruggiero had been discharged from the IPD. Officer I also said
that Mr Ruggiero was presenting as erratic.
93. At 9.13am, Mr Ruggiero pressed his emergency cell bell. CCTV footage shows a
prisoner deactivated the cell bell by pressing the panel outside Mr Ruggiero’s cell at
9.19am.
94. Mr Ruggiero pressed his cell bell a further twelve times up until 9.28am. All were
deactivated by the same prisoner. Several other prisoners looked through Mr
Ruggiero’s cell door observation panel and alerted Officer J who went to another
cell and left without checking Mr Ruggiero. CCTV footage shows ongoing activity,
with several prisoners looking into Mr Ruggiero’s cell and trying to talk to him.
95. At around 9.33am, Officer J went to Mr Ruggiero’s cell, knocked on the door, and
looked through the cell observation panel for around a minute.
96. At an unknown time afterwards, Officer J spoke to SO C and told him he was
concerned about Mr Ruggiero’s behaviour and asked whether he should be in the
IPD. SO C told the investigator he explained to Officer J that he thought this was
normal behaviour for Mr Ruggiero. He said he had known him for a long time and a
doctor needed to make any decision about him returning to the IPD. He
remembered advising Officer J to check on Mr Ruggiero in line with his ACCT
observations and to ‘keep popping down to see him’.
97. SO C thought he would have probably told Officer J that they would see how Mr
Ruggiero was later that day as he would not want to lock someone in their cell all
day. Officer J recalled SO C asked if Mr Ruggiero was secured in his cell and
commented they were now safeguarding him from other prisoners whom they were
concerned would assault him.
98. Officer I and SO C advised Officer J to document their concerns in security
intelligence reports. Officer I reminded Officer J to ensure his ACCT was updated
and make an entry in Mr Ruggiero’s prison records to reflect his concerns.
99. At the same time, Officer G was supervising prisoners on the exercise yard. He told
the investigator that he could see and hear Mr Ruggiero through his cell window
which was across a pathway between the wing and exercise yard. Officer G told the
investigator that Mr Ruggiero called to him and said he should be unlocked. Officer
G told him he had been instructed not to unlock him. Officer G said that Mr
Ruggiero then started damaging items in his cell and threatened to kill himself. He
said Mr Ruggiero did not have anything around his neck at that point.
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100. Officer G told the investigator that he asked Mr Ruggiero why he wanted to kill
himself to which he replied he wanted to be out (of his cell). Officer G said he was
unable to calm Mr Ruggiero and therefore went inside to speak to staff. He told
Officer I that Mr Ruggiero was damaging his cell and said he was going to kill
himself. He asked him to check on him.
101. Prisoner A was on the exercise yard and saw Mr Ruggiero across the pathway. He
told the investigator that he noticed Mr Ruggiero at his cell window, with a ligature
around his neck and with one hand on it.
102. Officer G said that he went back to the exercise yard and checked on Mr Ruggiero
by looking through his window around five minutes later. He saw Mr Ruggiero had a
ligature around his neck and had his finger underneath it. Officer G said he rushed
back inside and saw Officer H and Officer I. He told the investigator that he told
them it looked like Mr Ruggiero was hanging himself.
103. At around 9.50am, Officer H went to Mr Ruggiero’s cell and looked through his cell
observation panel. He told the investigator that he saw Mr Ruggiero hanging, with a
ligature around his neck. Officer H radioed a medical emergency code red (used
when a prisoner has significant blood loss).
104. Officer H struggled to open Mr Ruggiero’s cell door due to debris from his damaged
sink and toilet against the door. He pushed the door open and went in at 9.51am.
He cut the ligature from Mr Ruggiero’s neck.
105. Officer I heard an emergency code red called over his radio. At 9.51am, he ran to
Mr Ruggiero’s cell and saw Officer H inside. He radioed to change the emergency
call to a code blue (used when a prisoner is unconscious or not breathing). They
moved Mr Ruggiero onto the floor by his bed and checked if he was breathing.
106. At 9.54am, Nurse G went into Mr Ruggiero’s cell with an emergency bag. Officers
and Nurse G began cardiopulmonary resuscitation (CPR). Mr Ruggiero was moved
onto the landing, where there was more space and other nurses assisted.
107. The ambulance service received a call from the control room at 9.54am. At
10.12am, an ambulance and paramedics arrived. They were escorted to B Wing
and arrived at 10.22am. Paramedics stabilised Mr Ruggiero and moved him to
close by the emergency air ambulance which landed in the grounds at 11.08am.
108. At 12.43pm, Mr Ruggiero’s condition deteriorated as paramedics were preparing to
move him into the air ambulance and paramedics resumed CPR. Despite their best
efforts, at 1.43pm, they pronounced life extinct.
Contact with Mr Ruggiero’s family
109. At 2.16pm on 16 November, the prison appointed Officer K as the family liaison
officer. Officer K and CM A began travelling to visit Mr Ruggiero’s uncle who was
listed as his next of kin. It became apparent the address listed did not exist so they
asked the duty manager at Swaleside if they could find an address for Mr
Ruggiero’s mother whom they knew had regular contact with him.
110. Officer K and CM A arrived at Mr Ruggiero’s mother’s house at around 7.30pm that
evening. As there was no response, they waited at the address and contacted the
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duty manager at Swaleside to ask for a telephone number for Mr Ruggiero’s sister.
The number recorded did not connect.
111. The following morning, security staff gave Officer K Mr Ruggiero’s mother’s
telephone number. She telephoned her, informed her of his death and offered
support. The prison contributed towards the cost of Mr Smith’s funeral in line with
national policy.
Support for prisoners and staff
112. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
113. After Mr Ruggiero’s death, Mr H, the duty governor, debriefed the staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
114. The prison posted notices informing other prisoners of Mr Ruggiero’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Ruggiero’s death.
Post-mortem report
115. The pathologist gave Mr Ruggiero’s cause of death as hanging. The pathologist
found therapeutic levels of fentanyl and lamotrigine in his system. Alcohol was also
identified in his system at above the legal driving level. No alcohol was found in Mr
Ruggiero’s cell after he died.
Inquest
116. At an inquest held between 9 and 20 March 2026, the Coroner concluded that Mr
Ruggiero died by ligaturing himself in circumstances where his intention could not
be ascertained.
117. The Coroner concluded that during Mr Ruggiero’s time in IPD, there was a failure to
complete the ACCT Care Plan and a lack of full attendance at ACCT reviews, which
led to missed opportunities for all staff to understand Mr Ruggiero's triggers and
other vital information in order to care for him. Subsequently, there was a missed
opportunity, as not all medical professionals were aware at the time of his return to
B Wing on 14 November that he had attempted to tie a ligature around his neck on
12 November.
118. Prison staff’s ability to react to Mr Ruggiero’s distress on the 14 November was
reduced by the other prisoners resetting his cell bell. In the hour preceding Mr
Ruggiero's death, the communication between prison staff was insufficient and
lacked clarity. Opportunities to increase formal observations or notify health care
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were missed. Staff communications failed to relay the severity of the situation and
there was a further delay in emergency response.
119. The Coroner issued three Prevention of Future Deaths reports (also known as
Regulation 28 reports), which can be issued following an inquest to highlight
concerns and request action to prevent similar deaths in the future. The reports
were directed to HMP Swaleside, Oxleas NHS Foundation Trust, and the Minister of
State for Prisons, Probation and Reducing Reoffending, identifying actions required
to prevent similar future deaths.
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Findings
Assessment of risk
120. The Prison Safety Policy Framework requires all staff who have contact with
prisoners to be aware of the risk factors and triggers that might increase a
prisoner’s risk of suicide and self-harm and to manage prisoners identified as at risk
under ACCT procedures.
121. Mr Ruggiero had a number of evident risk factors for suicide and self-harm,
including a history of self-harm including potentially lethal ligature tying, a history of
substance misuse in the community and in prison and serious mental health
concerns. During his two years at Swaleside, staff appropriately started ACCT
procedures thirteen times and Mr Ruggiero spent five periods under constant
supervision. Prison staff appropriately began ACCT procedures on 27 October after
Mr Ruggiero made cuts to his arms and legs, and initial actions were timely. We
have considered the management of this last period of ACCT monitoring.
122. During the initial ACCT assessment, the assessor noted that it was difficult to
engage Mr Ruggiero due to his mental state. We understand exploring Mr
Ruggiero’s external support network could not happen due to his presentation and
the assessment identified some risks, triggers and protective factors. However, key
areas which directly related to his risk of suicide and self-harm were not recorded.
For example, Mr Ruggiero’s drug use, history of self-harm (including self-
strangulation) and non-compliance with medication were not identified.
123. ACCT reviews were timely, with most chaired by the case manager and appropriate
staff in his absence. Healthcare staff rarely attended in person. SO B said he had
spoken to healthcare staff, and this was evidenced by information documented in
reviews which he could only have known by speaking to IPD nurses. He told the
investigator that he was aware his record keeping was poor, and this was
something he would improve.
124. Mr Ruggiero’s care plan was blank, with no actions documented. SO B said it was
clear he and others had considered and taken some actions to support Mr Ruggiero
and manage his risk, however, this was not recorded. SO B told the investigator
that in managing ACCT generally, if a problem could be solved quicky through a
simple action, this would be done and therefore there was no longer a need to
record it. He suggested there were times when staff felt “held to ransom” by care
plans, particularly if they thought prisoners were abusing the process to achieve
goals such as a transfer. SO C told the investigator that if there was nothing on Mr
Ruggiero’s care plan, it meant he either did not need any support or it was already
being provided through the mental health team and SOS.
125. The investigator looked at three other ACCTs on B Wing in January 2025. None
had care plans. Our investigation found that staff understood care plans and
expectations to complete them. However, staff did not always see the value or
importance of completing care plans and sometimes felt restricted by them.
126. While we were pleased that our investigation found that all observations recorded
took place and correlated with CCTV footage, observation intervals did not always
reflect the risk Mr Ruggiero posed. Specifically, on 28 October, the frequency of
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staff checks was reduced despite Mr Ruggiero declining to engage in the review,
and staff noting he had been up all-night shouting and was clearly still unwell. Mr
Ruggiero’s constant supervision that commenced on 8 November ended on 14
November. Our investigation found that the decision to stop constant supervision
was reasonable. However, we found that the frequency of checks was reduced too
quickly to just one an hour and did not reflect the risk posed. We found this to be a
systemic issue at Swaleside. Mr Ruggiero was frequently monitored under constant
supervision, but when that ended, staff often reduced the frequency of checks to
one an hour – the lowest frequency of checks despite evidence that his risk
remained significant. The ACCT guidance allows for a range of check frequencies,
which staff can adapt according to the assessed level of risk. We are concerned
that staff at Swaleside essentially consider only two options: constant supervision or
one check an hour which limits the support available to prisoners at risk.
127. Our investigations into five of the previous self-inflicted deaths at Swaleside
identified deficiencies in the way the prison managed suicide and self-harm
procedures (ACCT). We consider some of the issues identified in this investigation
reflect ongoing significant systemic issues in the delivery of ACCT at the prison. We
therefore escalate our concerns as follows:
The Executive Director for the Long Term and High Security Estate and the
Governor should formulate a robust plan, with sufficient oversight and
auditable measures to ensure that prison staff manage prisoners at risk of
suicide and self-harm in line with the Prison Safety Policy Framework, and in
particular, they should:
• hold and accurately record multidisciplinary reviews, with healthcare
staff and other relevant staff providing detailed input if they are unable
to attend;
• set a frequency of observations appropriate to the level of risk; and
• ensure care plans are fully completed, person-centred and responsive
to risk.
Mental health care
128. The clinical reviewer concluded that the care Mr Ruggiero received at Swaleside
was not equivalent to that which he could have expected to receive in the
community. She found it was not clear from the clinical records or interviews that
there was any professional curiosity about the correlation between Mr Ruggiero’s
trauma and his mental state. This led to Mr Ruggiero moving from service to service
in a reactive manner rather than services being proactive in creating treatment
plans.
129. Mr Ruggiero spent periods in the IPD when his mental health deteriorated as a
result of PS use. Admissions to the IPD or being held in the segregation unit
enabled Mr Ruggiero to stop using drugs, take his medication and stabilise his
mental health. However, he quickly relapsed on discharge and struggled to maintain
progress. This led to frequent crisis periods and a repetitive cycle of readmission to
the IPD. He was not referred to the complex case panel (where all services attend
to review the needs of a prisoner to ensure that the right treatment is being provided
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by the right service). This would have allowed services to identify that there may
have been too many professionals involved in his care and that this may have
contributed to his lack of engagement and willingness to discuss his mental health.
The clinical reviewer made recommendations related to Mr Ruggiero’s death and
we repeat them here:
The Head of Healthcare should ensure that:
• healthcare staff are involved in all ACCT reviews while a prisoner is in
the IPD; and
• an audit of treatment plans is undertaken to ensure that they are clearly
documented in the clinical records and reviewed.
Substance misuse treatment
130. Mr Ruggiero was given several opportunities to engage with the substance misuse
service. Staff made efforts to assess him and provided harm reduction advice.
However, his motivation to engage fluctuated. He declined to engage in three
assessments offered in 2023, and in July 2024 signed a declaration form to confirm
he did not want to engage with the service. Shortly before his death he referred
himself to the service and engaged in an assessment the day before he died. We
consider that Mr Ruggiero understood how to access substance misuse services
and was offered appropriate support.
Governor to note
Cell bells
131. Cell bell records evidence that Mr Ruggiero pressed his emergency cell bell twelve
times between 9.13am and 9.28am on 16 November. CCTV footage showed a
prisoner quickly deactivated these by pressing the panel outside Mr Ruggiero’s cell.
Although these would have displayed on the cell bell panel in the staff office, staff
could not reasonably have noticed or responded to Mr Ruggiero’s cell bell given
how quickly they were deactivated. The Governor will want to consider whether
there is any learning from this to ensure that prisoners do not routinely deactivate
other cell bells.
Emergency response
132. While we recognise that the officers who responded to the emergency felt scared
and shaken and therefore did not activate their body-worn video cameras
immediately, it is important to do so.
133. An incorrect emergency code was called when staff found Mr Ruggiero. This was
rectified quickly but the Governor may wish to consider whether any further action is
required.
134. Swaleside’s control room log documents the emergency code red at 9.49am and
the change to a code blue at 9.52am. Ambulance records show they received a
telephone call from Swaleside at 9.54am. The Governor will want to assure herself
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that staff in the control room call for an ambulance without delay on hearing a
medical emergency code.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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