Thomas Ruggiero

I am Mr. Ian Potter, area coroner for Kent and Medway

On 18 November 2024 an investigation into the death of Thomas Daniel RUGGIERO was  commenced. The investigation concluded at the end of the inquest heard by me and before a jury between 9 – 20 March 2026. The conclusion of the inquest was: Mr Ruggiero died by ligaturing himself in circumstances where his intention could not be  ascertained. Hanging

Thomas Daniel Ruggiero was 39 years of age at the time of his death. He was serving an eight year prison sentence. At the time of his death he was held at HMP Swaleside. Mr Ruggiero had complex mental health needs and his diagnoses included severe Emotionally Unstable Personality Disorder (EUPD), Antisocial Personality Disorder (ASPD), and  Polysubstance misuse. As a result of these diagnoses, Mr Ruggiero was well known to self- harm and was at heightened risk. He had been subject to the ACCT provisions on numerous  occasions and had had multiple stays in the in-patient unit or IPD at HMP Swaleside. While still subject to the ACCT and requiring hourly observations, Mr Ruggiero was found  unresponsive in his cell at HMP Swaleside on the morning of 16 November 2024, having  ligatured. Following attempts at treatment and resuscitation, Mr Ruggiero died at the prison  later that day.

During the course of the inquest the evidence revealed matters giving rise to concern. I must  acknowledge that some of the concerns relating to Oxleas NHS Foundation Trust do appear to have been addressed and, as such, those concerns do not feature as part of this report. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – (1) There is a policy requirement / expectation that a member of the healthcare team should  attend all ACCT reviews. In this case, there were numerous instances that this was not met.  While I heard evidence of some improvement, it was accepted that there were ongoing issues  with securing the attendance of the mental health team (where required) at ACCT reviews. I  was insufficiently reassured that the matter has been addressed and I consider that there is  ongoing risk to particularly vulnerable prisoners for whom the ACCT processes should act as a safety-net and protective factor.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.