Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0171, written 24 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Mar 2026 |
|---|---|
| Reference | 2026-0171 |
| Deceased | Thomas Ruggiero |
| Coroner | Ian Potter |
| Coroner area | Ian Potter |
| Category | State Custody related deaths |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Date: 24 March 2026 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Oxleas NHS Foundation Trust 1. CORONER I am Mr. Ian Potter, area coroner for Kent and Medway 2. CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 18 November 2024 an investigation into the death of Thomas Daniel RUGGIERO was commenced. The investigation concluded at the end of the inquest heard by me and before a jury between 9 - 20 March 2026. The conclusion of the inquest was: Mr Ruggiero died by ligaturing himself in circumstances where his intention could not be ascertained. 1a Hanging 1b 1c 1d II 4. CIRCUMSTANCES OF THE DEATH 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. 5. CORONER'S CONCERNS 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. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 May 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Mr Ruggiero's family • Ministry of Justice I have also sent it to the Care Quality Commission and the Prison and Probation Ombudsman who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 24 March 2026 Ian Potter Area Coroner for Kent and Medway
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