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recurance

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Thomas Ruggiero (3)

24 Mar 2026 · Coroner Ian Potter · Ian Potter
Check this reportOriginal

The coroner's concerns

  1. 1. emergency cell bell system vulnerable to misuse and abuse

    “Emergency Cell Bell System”

  2. 2. incomplete ACCT documentation and staff undervaluing its importance

    “ACCT documentation and staff approach to this”

  3. 3. insufficiently experienced staff and poor communication during crisis

    “Staffing / Experience / Communication etc.”

Responses

2026-0172-Response-from-HM-Prison-Probation-Service.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error