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.