Prisoners were able to silence a distressed inmate’s emergency call bell before he became the ninth inmate to take his own life in three years at the jail.
Thomas Ruggiero, 39, was found in his cell at HMP Swaleside, on the Isle of Sheppey, on November 16, 2024.
He had been serving an eight-year sentence for assault and struggled with his mental health.
A jury inquest, held between March 9 and 20 at Oakwood House in Maidstone and led by coroner Ian Potter, concluded he died by ligaturing himself in circumstances where his intention could not be ascertained.
In his report, which has since been submitted to the prison, Mr Potter warned there was a “significant” risk that further deaths could occur unless action is taken.
He raised concerns about the jail’s emergency cell bell system, suicide and self-harm procedures, staff communication and experience, and confusion over emergency response codes.
CCTV footage showed other prisoners silencing Ruggiero’s cell bell from outside his door in the hour before he was found unresponsive.
The jury found this hampered staff’s ability to respond to his needs and distress.
Mr Potter said anyone could cancel an emergency call bell at the push of a button outside a cell, with staff then assuming the call had been answered.
He warned the system remains “highly vulnerable to both misuse and abuse”.
“The evidence was that as and when a cell bell is silenced, staff assume that the call for assistance has been answered,” said the coroner.
“There was clear evidence that this situation has not changed in any way since November 2024.”
The inquest also highlighted concerns around the lack of experience among staff. At the time of Ruggiero’s death, at least 90% of the prison officers at HMP Swaleside were new in post and still in their probationary period.
The supervising officer admitted he “possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe”.
In his report to the prison, Mr Potter said: “Without sufficient numbers of experienced prison officers across the prison estate, the staffing issues seen in this particular inquest are likely not isolated. I highlight to you my concern that high levels of inexperienced staff will undoubtedly contribute to future deaths of those in custody.”
He added: “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.
“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 governor of HMP Swaleside has until May 18 to respond to Mr Potter’s findings, while the Ministry of Justice and healthcare providers have until May 19 to outline what action will be taken, or explain why none is proposed.
It comes as the jail was named the worst in the country in a damning report by the Chief Inspector of Prisons, which found high levels of drugs and violence and called on the government to take urgent action to fix it.
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