23 Mar 2026 Thomas Daniel RUGGIERO · Prevention of Future Deaths report Kent and Medway
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Concerns raised 6 Failure to restrict emergency cell bell silencing to staff View source Confusion among prison staff about when and how to call a code blue View source Failure of prison staff communication to relay the severity and complete scope of situations View source Failure to complete ACCT care plan documentation View source Failure of landing officers to intervene in poor behaviour at prisoners' cell doors View source Insufficient staffing mix of skills and experience to keep the wing safe View source See 3 more concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Daniel RUGGIERO · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict emergency cell bell silencing to staff
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Confusion among prison staff about when and how to call a code blue
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison staff communication to relay the severity and complete scope of situations
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ACCT care plan documentation
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of landing officers to intervene in poor behaviour at prisoners' cell doors
Wider context from the report “(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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing mix of skills and experience to keep the wing safe
Wider context from the report “(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.
” Open source report
8 Aug 2024 Sean Martin DAVIES · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Lack of required operational support group officer training in fire regulations and handovers View source Failure of operational support group officers to act in accordance with training View source Failure to conduct prisoner welfare checks in line with national guidance and local policies View source Potential suicide and self-harm risk among prisoners subject to IPP sentences View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sean Martin DAVIES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sean Martin Davies, who was serving an indeterminate sentence for public protection at HMP Swaleside, died by suspension in his cell on 25 February 2023. He had expressed hopelessness and left a note linking his death to the IPP sentence. Concerns included risk assessment and management for prisoners subject to IPP sentences, welfare checks not being conducted in line with guidance or policy, and shortcomings in staff training and handovers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of required operational support group officer training in fire regulations and handovers
Wider context from the report “(3) One operational support group officer had not received training in relation to fire regulations or handovers , another did not act in accordance with the training
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of operational support group officers to act in accordance with training
Wider context from the report “(3) One operational support group officer had not received training in relation to fire regulations or handovers, another did not act in accordance with the training
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prisoner welfare checks in line with national guidance and local policies
Wider context from the report “(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Potential suicide and self-harm risk among prisoners subject to IPP sentences
Wider context from the report “(1) There are currently 55 prisoners at HMP Swaleside subject to IPP sentences. It has been recognised by the Prison and Probation Ombudsman that an IPP sentence should be regarded as a potential risk factor for suicide and self harm (learning lessons bulletin September 2023). In the clinical review following the death of Mr. Davies a recommendation was made that the Governor and Head of Healthcare ensure that a risk formulation was completed for all prisoners subject to IPP sentences, that it was regularly reviewed and updated including where there has been an event that may increase a person's risk of suicide and self harm. Such formulation should be made readily available for all staff to refer and be stored within the prison and medical records. I understood from representations made on behalf of the Ministry of Justice that a 'national strategy' was intended for IPP prisoners. At the end of the inquest I gave the Governor and Head of Healthcare some time to notify me of the steps that had been taken in relation to the recommendation of the clinical review and any interim measures in respect of the 'national strategy'. Whilst I have been provided with the changes in practice that have been put in place by Head of Healthcare, I have been asked by the safer custody team at HMP Swaleside to issue a Regulation 28 report so that a considered response can be provided in relation to this matter and the concerns below
” Open source report
24 Jan 2022 Idris HABIB · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 4 Failure to align local roll-check policy with entry-level officer training View source Failure to document welfare checks as having taken place View source Failure to ensure welfare checks are conducted without being overlooked View source Failure to remove previous occupants' medication from cells View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Idris HABIB · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Idris Habib was found suspended in his cell at HMP Swaleside after incidents involving self-harm, a cell fire and statements that he was being bullied and wanted to kill himself. The inquest concluded that he took his own life by hanging, although his intention was unclear. Concerns included medication from a previous occupant being found in the cell, a disconnect between local policy and training on roll checks, and the need to ensure welfare checks were conducted and documented.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to align local roll-check policy with entry-level officer training
Wider context from the report “(2) There was a disconnect between HMP Swaleside's local policy and the Prison Officer Entry Level Training in respect of roll checks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to document welfare checks as having taken place
Wider context from the report “(3) That measures put in place following Mr. Habib's death to ensure welfare checks are conducted are not overlooked and are documented as having taken place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure welfare checks are conducted without being overlooked
Wider context from the report “(3) That measures put in place following Mr. Habib's death to ensure welfare checks are conducted are not overlooked and are documented as having taken place
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to remove previous occupants' medication from cells
Wider context from the report “(1) Medication from the previous occupant of cell B1-18 was found in the cell following the death of Mr Habib
” Open source report
13 Jul 2015 Douglas Birch · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to read Prison Service Orders and Instructions View source Failure to receive Prison Service Orders and Instructions View source Failure to elicit a prisoner response upon cell unlocking View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Douglas Birch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Douglas Birch was a serving prisoner at HMP Swaleside who was found dead in his cell on 15 May 2013, having died between 19:10 on 14 May and 07:10 on 15 May. The concerns were that officers did not elicit a response when unlocking his cell as required by PSI 75/2011, and that officers may not have received or read relevant Prison Service Orders and Instructions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to read Prison Service Orders and Instructions
Wider context from the report “(2) Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to receive Prison Service Orders and Instructions
Wider context from the report “(2) Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swaleside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to elicit a prisoner response upon cell unlocking
Wider context from the report “(1) Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations