Rickie Poon

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 
REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 
2013 

Please do not include any living persons’ names in this document, in 
accordance with the Chief Coroner’s PFD Publication Policy (2026). 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, ME Hassell for the Coroner Area INNER NORTH LONDON in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following 
an inquest into the death of Rickie Poon that concluded on 26 March 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, Practice Plus Group (PPG) provides this response within 
56 days (plus any extension granted) of the date of the Report to Prevent 
Future Deaths. 

2.  DATE OF RESPONSE 

21st MAY 2026 

3.  CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

For HMP Pentonville  

The jury found that the following failures at HMP Pentonville in the ACCT 
(assessment care in custody and teamwork) process contributed to Mr Poon’s 
death:  

• 

the ACCT process was not managed and implemented properly, e.g. 
supervising officers did not consistently acquaint themselves with case 
notes or history when completing reviews; record keeping was 
inadequate; agreed actions were not consistently implemented; and 
ACCT reviews lacked structure and consistency;  

•  accountability was insufficient, e.g. there was no follow up when actions 

were missed in the ACCT document, sign offs were completed 
inaccurately, hand overs were not completed between staff, and an 

 
 
 
 
 important email was not read or followed up on;  

there were gaps in training and knowledge, e.g. ACCT training had 
expired and prison staff overly relied on Rickie’s presentation;  

the ACCT was closed too soon.  

• 

• 

The jury also found that the level of ACCT observations was reduced 
inappropriately, but they were unclear as to whether this impacted on the 
outcome.  

I recognise that there have been many changes at HMP Pentonville since Mr 
Poon’s death just over a year ago, but I consider it important to bring the jury’s 
findings on causative failures specifically to your attention.  

For PPG  

The nurse who was on duty for medical emergencies on the night that Rickie 
was found hanging (call sign Hotel 7), attended immediately upon a code blue 
alarm being raised. She found prison officers undertaking cardiopulmonary 
resuscitation (CPR), and so, despite the fact that she had formed the firm and 
correct view that Mr Poon was dead and that CPR was completely futile, she 
then undertook chest compressions and continued it.  

I did not explore with the nurse the competence of the CPR given.  

The nurse’s actions could not have had an impact on the outcome because Mr 
Poon was already dead when she arrived. However, conducting CPR on a 
person who had clearly died was not professional or appropriate, it did not 
afford Mr Poon dignity or privacy, it was neither acceptable nor kind.  

What concerns me particularly for the future is that there might be an occasion 
when a CPR attempt that is less than fully competent does have the potential 
to impact on the outcome.  

I sent PFD reports to PPG’s earlier incarnation, Care UK, and/or HMP 
Pentonville about the nature of attempts at resuscitation in respect of the 
following deceased:  

•  William Davies (2014)  

•  Adil Habib (2015)  

•  Samuel Blair (2016)  

•  Tedros Kahssay (2016)  

•  Amir Faizi (2018)  

•  Robert Ginn (2019)  

I recognise that I made the last of these reports over six years ago and I have 

 heard descriptions of many changes since then, but I consider that I would be 
failing in my duty if I were not to flag up this issue now. I hope that by doing so, 
such a situation will be less likely to arise in the future. 

3. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 
[If no action is proposed please explain why here]. 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

We do not propose to respond to the points raised above in respect of HMPPS 
and HMP Pentonville as these matters are for separate organisations. 

In respect of the concern raised for PPG and the CPR attempt in this matter, 
we are disappointed that it was inappropriate given the presentation of Mr 
Poon. However, we are glad to hear that you are aware of the changes and 
improvements made over the last few years. 

It is important to note that all clinical staff are trained to ILS (Immediate Life 
Support) standards. This is a RCUK accredited course for healthcare 
professionals to manage patients in cardiac arrest before the ambulance team 
arrives. It focuses on the ABCDE approach, airway management, and safe 
defibrillation. All staff are expected to complete this training which is done 
yearly to ensure ongoing competence. This is also subject to audit, which 
currently shows a 74% compliance rate. Anyone who does not have the 
training in date would not be assigned to an emergency radio and would be 
expected to book and complete the training as soon as possible. There is a 
session booked on the week commencing 25th June 2026 which will raise the 
compliance to over 90%. The ILS course is delivered by an external provider, 
but PPG have worked with the company who deliver this training, so the 
course does include a module on recognition of life extinct (ROLE) and has 
done since 2021.  

In this case, the nurse in question did have her ILS training in date and 
therefore had completed the necessary training to carry out her duties. Whilst 
we agree in this case that CPR should have been stopped given Mr Poon’s 
presentation, it must be recognised that stopping CPR in such circumstances 
is a difficult decision to make. As per the letter sent to His Majesty’s Coroner 
by the Head of Healthcare during the inquest, this will be explored further with 
the nurse in question and additional measures have been put in place to 
support them and aid in improving their practice. This case is also due to be 
discussed with the Director of Nursing in an upcoming meeting about 
resuscitation detailed later in this response.  

Guidance on the distinctions between verification of the fact of death, 
certification of death, and the appropriate clinical responses to observations is 
already embedded in the annual Immediate Life Support (ILS) training. A 
dedicated module on this topic was specifically developed for PPG and has 
been included in the training programme since 2021. Alongside mandatory 
training, regional education sessions have been delivered to further support 
staff in developing clarity and confidence in these areas.  

We also routinely distribute updated guidance from national bodies, including 
the Resuscitation Council and NICE, to ensure alignment with current best 

 practice.  

In addition, we consistently reflect on relevant incidents through both hot and 
cold debriefs, as well as ongoing reflective practice sessions. These forums 
provide opportunities for staff to discuss the practical differences between 
verification, certification, and clinical decision-making, reinforcing learning and 
supporting continuous improvement.  

A purple alert (which is a companywide safety notification) was published for 
all Heads of Healthcare to action, which clarified the organisational position on 
cardiopulmonary resuscitation following updated guidance by NHSE on 19 
March 2026, which is being actioned in line with the deadline given in the alert. 
A copy of this alert is attached to this response for ease of reference. The 
purple alert highlights to all services within Practice Plus Group (PPG) that we 
fully support the national HMPPS/NHSE guidance that cardiopulmonary 
resuscitation (CPR) should begin immediately when an individual is 
unresponsive, not breathing and/or has no pulse, unless there are 
unmistakable signs of irreversible death. However, it recognises that PPG’s 
clinical training model differs from the national assumption that prison 
healthcare staff are trained only to Basic Life Support (BLS) level. Since 2021, 
PPG has delivered both BLS and Immediate Life Support (ILS) training across 
its Health in Justice workforce. The ILS programme includes formal training in 
Recognition of Life Extinct (ROLE), enabling clinicians to make safe, 
defensible decisions about when resuscitation would be futile. 

Under this framework: 

trained staff are required to commence CPR immediately unless there are 

BLS
clear, catastrophic signs incompatible with life. If uncertain, they must begin 
trained clinician. 
CPR and escalate to an ILS

‑

trained clinicians are expected to apply their enhanced clinical judgement, 

ILS
including ROLE principles, to determine whether CPR is appropriate. Where 
resuscitation would be futile, they may withhold or cease CPR, provided the 
decision is clinically justified and properly documented. In any situation of 
doubt, CPR should still be initiated. 

‑

‑

The site has already implemented this guidance locally. A reminder has been 
issued to all staff to ensure clarity on the distinction between BLS and ILS 
expectations and the correct application of ROLE principles. 

In light of the Prevention of Future Deaths (PFD) report, the site has also 
requested a meeting with the Regional Director and the Director of Nursing, 
due to be held in June 2026. The purpose of this meeting is to: 

•  Review the guidance in the context of the PFD. 

•  Consider whether further scoping is needed as we have members of 
clinical staff who may have adjustments for example, where this 
guidance is less clear in the context of the overall service. 

•  Assess safe staffing numbers trained to ILS/ROLE in light of these 

restrictions and overall staffing picture. 

As a service, we are committed to further strengthening our resuscitation 
response following the issues highlighted in the PFD. To support this, we are 
introducing multidisciplinary, scenario-based training by July 2026. This 
programme will involve healthcare staff, prison staff, and prisoners where 
appropriate, ensuring that learning is shared across the whole custodial 
environment and that all parties understand their roles during a medical 

 emergency.   

RCUK guidelines recognise that CPR may be stopped when it becomes clear 
that continued efforts are futile, for example, when there is no return of 
spontaneous circulation despite appropriate interventions, or when the clinical 
picture confirms irreversible death such as Rigor Mortis. Embedding these 
based training will help ensure that clinicians apply 
standards into scenario
consistent, evidence
making when determining whether to 
continue or cease resuscitation and the aim is to give them the confidence to 
make these decisions as these scenarios will pre-expose them to situations 
where they may have to make a decision to stop CPR, in a multidisciplinary 
scenario. 

based decision

‑

‑

‑

The Head of Healthcare has also discussed this regionally and there will be 
further learning sessions delivered within the region on ROLE, for staff to join 
in bitesize learning sessions online, this had been delivered previously, so is 
already available.  

4.  DETAILS OF FURTHER ACTION PROPOSED 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

Copy of Purple Alert 

SIGNATURE 

Medical Director