Thomas Ruggiero (2)
24 Mar 2026 · Coroner Ian Potter · Ian Potter
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of mental health team attendance at ACCT reviews
“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.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
This report
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”