Swaleside Prison

Justice · Prison or young offender institution

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First report 13 Jul 2015•Latest report 23 Mar 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
4

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Swaleside Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Kent and Medway

    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

  2. Mid Kent and Medway

    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

  3. Mid Kent and Medway

    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

  4. Mid Kent and Medway

    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

Data last updated 7 September 2026