Rickie Poon

I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Poplar Coroner’s Court  Bow Coroner’s Court

On  17  March  2025,  one  of  my  assistant  coroners,  Sarah  Bourke, commenced an investigation into the death of Rickie Poon, aged 38 years. The investigation concluded at the end of the inquest on 26 March 2026. The jury made a determination at inquest of death by suicide, plus a narrative that I now attach.

Following his arrest and suspension from the job of a police officer, Rickie Poon made a serious attempt on his life on 19 January 2025, was detained under section of the Mental Health Act, then remanded in custody at HM Pentonville on 13 February 2025.  By this time he had been dismissed from work. Exactly one month after his arrival in prison, he was found hanging in his cell.

During the course of the inquest, the evidence revealed matters giving rise to concern. 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 MATTERS OF CONCERN 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.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action