A coroner has strongly criticised a nurse at HMP Pentonville in North London for performing 'unkind and inappropriate' CPR on a deceased inmate, highlighting serious failings that contributed to his death.
Background of the Case
Rickie Poon, 38, a former Metropolitan Police officer, was dismissed from the force in 2024 after being arrested and released on bail awaiting trial for alleged sexual offences. On January 19, 2025, he made a serious suicide attempt and was subsequently remanded in custody at HMP Pentonville on February 13, 2025. Despite being placed on suicide watch, he took his own life exactly one month later.
Inquest Findings
A coroner's inquest concluded on March 26 that serious failings contributed to his death, particularly in the Assessment, Care in Custody and Teamwork (ACCT) process designed to support inmates at risk of self-harm or suicide. A jury found a 'lack of accountability' among officers, criticised 'inadequate' ACCT record-keeping, and noted 'inconsistent' reviews while Mr Poon was under observation.
Coroner's Report
In a Prevention of Future Deaths report published on April 10, Senior Coroner Mary Hassell warned prison governors that there was a risk of future deaths unless action was taken. She was particularly critical of a nurse employed by healthcare provider Practice Plus Group (PPG), who arrived at the cell after staff sounded the emergency alarm. Upon finding prison officers trying to revive Mr Poon, she correctly grasped that he was already dead but nonetheless took over and continued giving chest compressions.
The coroner described the nurse's actions as 'unprofessional, inappropriate, undignified, and unkind', expressing concern that a poor CPR attempt in the future could also lead to further deaths. Ms Hassell reminded the prison and PPG of several past warnings she had given regarding resuscitation attempts on deceased inmates, though her most recent report was six years ago.
Response and Ongoing Concerns
HMP Pentonville must respond to the report by June 1, 2026. This is the fourth Prevention of Future Deaths report sent to Pentonville governors this year, following the suicide of prisoner Mujahid Adam in 2025. The Ministry of Justice was approached for comment but did not respond in time for publication.
