Rickie Poon

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Independent investigation into
the death of Mr Rickie Poon,
A report by the Prisons and Probation Ombudsman
a prisoner at HMP Pentonville,
on 13 March 2025
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Rickie Poon was found hanged in his cell on 13 March 2025 at HMP Pentonville. He
was 38 years old. I offer my condolences to Mr Poon’s family and friends.
Mr Poon died a month after he arrived at Pentonville. He had several significant risk
factors for suicide and self-harm and had been assessed at court as presenting a risk of
suicide. While it is positive that suicide and self-harm support procedures (known as
ACCT) began in reception, the subsequent ACCT monitoring was poor. ACCT reviews
were not always multidisciplinary, and staff relied too heavily on Mr Poon’s presentation.
This meant that they misjudged his risk of suicide and self-harm. Our investigation into a
previous self-inflicted death at Pentonville in 2023 identified concerns with ACCT
management and staff misjudging the risk of suicide and self-harm. It is disappointing that
we found similar issues in this investigation. We also found that the frequency of ACCT
checks on Mr Poon was reduced too quickly, and the ACCT was closed prematurely. I am
concerned that pages of Mr Poon’s ACCT document remain missing and Pentonville have
been unable to explain their absence.
Mr Poon did not receive an induction or basic skills assessment. He did not have access to
purposeful activity which meant he spent most of his time in his cell.
When Mr Poon appeared at magistrates’ court on 13 February, magistrates noted that part
of their consideration for remanding him to prison was for his own protection following a
recent suicide attempt after he had been charged with offences. Prisons are very rarely,
and almost certainly not in the current capacity pressures, places of safety for people with
serious mental ill health or who are deemed at serious risk of suicide.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2026
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Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 17
2 Prisons and Probation Ombudsman
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Summary
Events
1. On 13 February, Mr Rickie Poon was remanded into custody at HMP Pentonville,
charged with sex offences.
2. Mr Poon was a former police officer and had attempted suicide less than a month
earlier which resulted in him being detained in a mental health hospital. Court staff
documented their concerns that Mr Poon’s risk of suicide and self-harm was high
and shared them with reception staff at Pentonville. During his reception
interviews, Mr Poon presented as calm and denied wanting to kill himself.
However, a nurse began ACCT procedures due to other factors which he
considered heightened Mr Poon’s risk of suicide and self-harm.
3. Mr Poon was managed as a vulnerable prisoner and moved from reception to the
vulnerable prisoners’ wing (where prisoners identified as vulnerable are kept
separate from the main prison population). He did not receive an induction or basic
skills assessment (which determines work allocation).
4. Staff were initially required to check Mr Poon once an hour and the frequency of
checks was reduced the following afternoon. Three days later, the safer custody
team emailed the three supervising officers of C Wing and D Wing, where Mr Poon
lived. They asked for the frequency of checks be increased back to once an hour
as they had received information which indicated Mr Poon’s risk of suicide was
high. Two supervising officers could not remember seeing the email, while another
recalled seeing it but did not take any action.
5. Mr Poon engaged in ACCT reviews on 14, 21 and 28 February (when the ACCT
was closed). He consistently denied thoughts of suicide and self-harm. Staff
considered that he presented as calm and well and said they felt like they were
talking to a colleague at times. An ACCT post-closure review took place on 8
March 2025, which concluded that Mr Poon did not pose an imminent risk as he
denied thoughts of suicide and self-harm.
6. At around 5.28am on 13 March, during a routine wing welfare check, an officer saw
Mr Poon hanging in his cell. Nurses and other prison staff arrived quickly and
noticed that Mr Poon’s body was stiff and he looked blue. They began
cardiopulmonary resuscitation. Paramedics arrived at 5.41am and at 5.48am, they
declared life extinct.
Findings
7. Mr Poon had significant risk factors that indicated he was at heightened risk of
suicide. Overall, we found that the prison failed to adequately assess and address
these risks.
8. Staff in reception appropriately began ACCT procedures in reception. The nurse
carefully considered all of Mr Poon’s risk factors and did not rely on his
presentation alone.
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9. During the initial assessment, ACCT case reviews and general interactions with
staff, Mr Poon consistently presented as calm and denied thoughts of suicide or
self-harm. His lack of a diagnosed mental illness and his calm presentation were
interpreted as evidence that he did not pose a risk of suicide, despite the objective
evidence to the contrary. We found that staff lacked professional curiosity, had a
poor understanding of suicide and self-harm risk and relied too much on Mr Poon’s
presentation. This led to decision-making which was ill-informed and compounded
by the absence of a multidisciplinary approach that included clinical oversight.
10. An email which the safer custody team sent the supervising officers on D Wing
was not actioned.
11. ACCT welfare checks were reduced too quickly (less than 24 hours after Mr Poon
arrived). His risk of suicide was consistently under-estimated and even when he
was considered at high risk of suicide, staff were never required to check him more
than once an hour. His care plan was insufficient to manage his risk and there was
a lack of recognition that many of Mr Poon’s risk factors could not be mitigated.
ACCT case management was inconsistent, and Mr Poon’s ACCT was closed
prematurely.
12. We are concerned that pages of Mr Poon’s ACCT remain missing.
13. Mr Poon said he felt lonely and bored at times. He spent most of his time in his
cell. In the week leading up to Mr Poon’s death, the prison did not provide him with
a full regime. While there were days when some activities and other services were
running, Mr Poon was unable to access them due to the lack of assessment and
induction.
14. Vulnerable prisoners who are taken straight to the Vulnerable Prisoners’ Wing from
reception do not always receive a timely induction and a basic skills assessment.
Prisoners on other locations are offered the opportunity to engage in induction the
day after they arrive; induction on the Vulnerable Prisoners’ Wing is offered once a
week. Although staff offered Mr Poon interim support (through other prisoners),
there is no evidence that he received a full induction or basic skills assessment.
Recommendations
• The Governor should ensure that there is a robust and effective quality
assurance process in place to monitor the quality of ACCT management,
focusing particularly on staff:
• identifying prisoners’ objective risk factors and basing assessment of
risk on them;
• setting meaningful and tailored care plan actions; and
• completing and properly securing all ACCT documentation.
• The Governor should ensure that prisoners located on the Vulnerable
Prisoners’ Wing receive a full induction, including a basic skills assessment,
within the first five days in custody, in line with PSI 07/2015.
4 Prisons and Probation Ombudsman
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The Investigation Process
15. HMPPS notified us of Mr Poon’s death on 13 March 2025.
16. The investigator issued notices to staff and prisoners at HMP Pentonville informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
17. The investigator visited Pentonville on 18 March 2025. She obtained copies of
relevant extracts from Mr Poon’s prison and medical records. She interviewed two
prisoners.
18. The investigator interviewed 10 members of staff and one prisoner at Pentonville
on 8 and 27 May. The investigator interviewed one member of staff in July.
19. NHS England commissioned a clinical reviewer to review Mr Poon’s clinical care at
the prison. Ms Macey and the investigator jointly interviewed healthcare and prison
staff.
20. We informed HM Coroner for London Inner North of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
21. The Ombudsman’s office contacted Mr Poon’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. He was concerned that
staff stopped ACCT monitoring for Mr Poon less than a month after he arrived at
Pentonville, despite mental health professionals having identified his risk of suicide
as extremely high. He was also concerned that after contact with nurses in
reception, no further mental health support appeared to have been put in place.
22. Mr Poon’s brother asked the following questions:
• What was the actual time of Mr Poon’s death?
• What plan was in place to protect Mr Poon from harming himself?
• How frequently was Mr Poon checked?
• During a social visit on 25 February 2025, he noticed Mr Poon had marks on
his neck. Were they documented by staff?
23. We have tried to address these questions in this report. However, we are unable to
say exactly when Mr Poon died.
24. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is an additional
annex to this report.
25. Mr Poon’s family received a copy of the draft report. The solicitor representing Mr
Poon’s family wrote to us raising a number of questions that do not impact on the
factual accuracy of this report. We have addressed these in separate
correspondence.
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Background Information
HMP Pentonville
26. HMP Pentonville is a local prison in London that primarily serves the courts of
north and east London. Practice Plus Group, in partnership with North London
NHS Foundation Trust, provides healthcare services.
HM Inspectorate of Prisons
27. The most recent full inspection of HMP Pentonville was in June and July 2025. The
full report is not yet available but a debriefing paper detailed initial findings.
Inspectors found that the care and support offered to new prisoners during their
first few days in prison was wholly inadequate. They found clear shortcomings in
the oversight of the first night and induction process and many prisoners
experienced a chaotic and frightening first few days at Pentonville as a result.
28. Inspectors found that the number of recorded self-harm incidents was similar to the
previous inspection and remained lower than other reception prisons. However,
only 37% of prisoners who had been on an ACCT said they felt cared for. Staff had
very limited knowledge of prisoners in their care or why they were on an ACCT,
including those under constant supervision. Inspectors observed a widespread lack
of support for prisoners at imminent risk of self-harm, many of whom lived in
squalid conditions. There had been four heads of safety in the previous two years,
and they had not addressed the poor care for prisoners at risk of suicide or self-
harm.
29. Inspectors concluded there were substantial weaknesses in the ACCT case
management documents. Inspectors found that Pentonville did not always respond
to PPO recommendations, and one PPO report had not been addressed at all. In
addition, investigations into serious incidents of self-harm were not always carried
out. They found that the prison had not addressed deficiencies identified
repeatedly in internal and PPO investigations.
30. Following the inspection, HM Chief Inspector issued an Urgent Notification, a
process which allows him to alert the Lord Chancellor if he has an urgent and
significant concern about the performance of a prison. He identified that the
governor needed significant support and investment from HMPPS, including
strengthening his senior team, to make measurable improvements in the future.
Independent Monitoring Board
31. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 March 2024, the IMB reported
some positive improvements in both reception and early days in custody. They
found that on arrival in reception, all relevant checks, processes and assessments
were in place and the IMB had observed a high level of professionalism and care
from staff and peer mentors.
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32. The IMB found that incidents of self-harm had increased by 13% compared to the
previous year but there were no identifiable themes behind this. They further
reported that inadequate completion of ACCT documentation remained an issue,
with important elements regularly not completed and insufficient evidence of
meaningful conversations. There was a detailed ACCT documentation audit
process in place, but the relevant checks were not consistent, and the IMB had not
seen any noticeable improvement in the quality of ACCT documentation.
Previous deaths at HMP Pentonville
33. Mr Poon was the seventh prisoner to die at Pentonville since March 2022. Of the
previous deaths, three were self-inflicted, two were due to natural causes and two
were drug-related. Our investigation into a self-inflicted death in 2023 identified
concerns with ACCT management and staff misjudging the risk of suicide and self-
harm.
34. Since Mr Poon’s death up until the end of July 2025, two prisoners have died at
Pentonville. One was due to an unknown cause. This remains under investigation.
The other prisoner apparently took his own life. There are no similarities between
the findings in that investigation and those following our investigation into Mr
Poon’s death.
Assessment, Care in Custody and Teamwork
35. HMPPS’ Prison Safety Policy Framework sets out the mandatory requirements for
staff on identifying risks of suicide and self-harm and supporting those at risk to
reduce harm. Assessment, Care in Custody and Teamwork (ACCT) is the Prison
Service case management approach used to support prisoners identified at risk of
suicide and self-harm. The framework states that all staff have responsibility for
ensuring that an ACCT is opened if they believe a prisoner is at risk of suicide or
self-harm. The purpose of ACCT is to try to determine the level of risk, how to
reduce the risk and how best to monitor and supervise the prisoner. After an initial
assessment of the prisoner’s main concerns, levels of supervision and interactions
are set according to the perceived risk of harm. There should be regular
multidisciplinary review meetings involving the prisoner.
Early days in custody and induction
36. As part of the early days in custody process, prisoners receive an induction to the
prison. Prisoners are given information about the prison regime, behaviour
expectations, facilities and how to access support. Basic skills assessments take
place and help identify suitable education and employment activities. Prison
Service Instruction (PSI) 07/2015 on Early Days in Custody sets out expectations
about when and how inductions should take place.
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Key Events
Background
37. In December 2024, Mr Rickie Poon, a serving police officer, was arrested on
suspicion of two sex offences and given bail. He was suspended from his job
pending criminal and internal gross misconduct investigations. Mr Poon had no
recorded history of suicide attempts or self-harm. He had no documented history of
mental illness or substance use issues.
38. On 19 January 2025, Mr Poon checked into a hotel in London and took an
overdose of prescription and over the counter medications. The following morning,
hotel staff telephoned the police as they saw Mr Poon acting strangely in the
reception area and were concerned for his welfare. Police arrived and took Mr
Poon to hospital.
39. Five typed letters, signed by Mr Poon and dated 19 January, were found. They set
out his plan to kill himself and included extensive information to enable his brother
to manage his financial affairs.
40. On 23 January, Mr Poon was detained under Section 2 of the Mental Health Act
(which allows compulsory detention of individuals for assessment of their mental
health for up to 28 days) and admitted to Chase Farm Psychiatric Hospital.
41. On 24 January, following an accelerated misconduct hearing, Mr Poon was
dismissed from the police service.
42. On 12 February, Mr Poon was discharged from Chase Farm. A psychiatrist, in
consultation with the Inpatient Clinical Director, wrote a discharge summary of Mr
Poon’s acute admission. They found no evidence of acute mental illness that
warranted ongoing admission to an acute ward, and Mr Poon did not meet the
criteria for further detention under the Mental Health Act.
43. They assessed that it was clear that Mr Poon viewed attempting suicide as a
rational and logical choice. Mr Poon told doctors that he could not guarantee that
he would not try to end his life again, but said he would never do this in the family
home due to the distress that would ensue and that he would be under his family’s
close watch. The doctors concluded that due to several risk factors, including the
degree of planning of his suicide attempt, his profession and ongoing investigation,
Mr Poon’s risk of suicide remained high in the community and prison. The
psychiatrist recommended that if Mr Poon went to prison, he should be flagged to
the in-reach mental health team. He offered to liaise with them directly.
HMP Pentonville
44. On 13 February, Mr Poon appeared at court, charged with sex offences. He was
remanded into custody and taken to HMP Pentonville. It was Mr Poon’s first time in
prison.
45. At 3.20pm, a court custody manager completed a suicide and self-harm warning
form. She documented that the court’s police liaison officer had raised concerns
8 Prisons and Probation Ombudsman
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about Mr Poon’s demeanour and behaviour, and she had been advised he was at
high risk of suicide and would harm himself at the earliest opportunity. She noted
he was to be kept on “five-minute constant watch [sic] whilst in custody” (which we
have taken to mean that he was being checked every five minutes) and advised
that Mr Poon should be prioritised.
46. At 5.09pm, a Serco prison escort and custody officer documented in Mr Poon’s
digital person escort record (DPER, which contains information about a prisoner’s
risk, offence, health and property) that Mr Poon had tried to kill himself on 19
January by overdose and had said he would try again when given the opportunity.
A court warrant supplement (which provides additional information about prisoners)
set out that Mr Poon had risk and vulnerability factors as he had attempted suicide
and expressed an intention to try again.
47. Mr Poon arrived at Pentonville at 5.20pm. At 5.21pm, a Serco officer (whose
signature is illegible) completed a First Night Centre priority process form which
incorrectly recorded that it was not Mr Poon’s first time in prison and that he had no
suicide or self-harm warnings.
48. At an unrecorded time, an officer interviewed Mr Poon in reception. He told the
investigator that he was told Mr Poon had a history of self-harm but did not recall
necessarily knowing the recent time frame. He said he would ordinarily receive a
‘court log’ from Serco (which details prisoners’ care and any concerns during their
time at court and transfer to prison) and other relevant documents such as a
warrant. He could not remember if he had seen the suicide and self-harm warning
form, the DPER or which documents were available to him.
49. The officer said he spoke to Mr Poon for between five and ten minutes, and the
main purpose was to complete the cell sharing risk assessment (CSRA). The
officer said that Mr Poon presented in a fairly upbeat manner. He thought Mr Poon
was ‘okay’ and did not seem that low in mood. Mr Poon denied thoughts of suicide
and self-harm. The officer told him how to access support from Listeners (prisoners
trained by the Samaritans to support other prisoners in crisis) and how to access
the Samaritans by phone.
50. The officer later documented in Mr Poon’s electronic prison record that it was his
first time in prison. Due to Mr Poon’s previous profession and the nature of the
alleged offences, the officer identified Mr Poon as vulnerable to threats and attack
from prisoners. He completed his CSRA and assessed him as high risk (which
meant he could not share a cell with other prisoners). The custodial manager (CM)
authorised this. Mr Poon accepted a space on the Vulnerable Prisoners’ Wing
(where prisoners considered vulnerable for a variety of reasons, including the
nature of any alleged offences, are kept separate from the general prison
population to reduce the risk of bullying and violence).
51. At around 6.02pm, the nurse completed Mr Poon’s initial health screen. He told the
investigator that he remembered receiving an email (he could not recall who sent
it) that a former police officer would arrive at Pentonville that evening. He was
aware Mr Poon had tried to kill himself recently and had been sectioned. He said
he read the DPER and noticed the suicide and self-harm warning.
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52. The nurse told the investigator that Mr Poon appeared calm, polite and settled. He
said there were no ‘red flags’ from his presentation and Mr Poon had denied
thoughts of suicide or self-harm. Despite his presentation, the nurse said he
opened an ACCT, based on his known risk factors. The nurse said he was
surprised that officers had not already opened an ACCT but that happened often,
and he thought this may be because some officers presumed it was not their job.
53. The nurse completed the ACCT concern form. He documented Mr Poon’s suicide
attempt, being detained under the Mental Health Act on 23 January, his previous
profession and the nature of the charges against him as risk factors. The nurse
referred Mr Poon to the early days in custody team for discussion the following
morning.
54. At around 6.15pm, the supervising officer (SO) received Mr Poon’s ACCT
document from the nurse and completed the immediate action plan. He noted Mr
Poon was to be in a single cell (in line with his CSRA) and reminded him how to
access Listeners. At around 6.45pm, the SO facilitated a welfare telephone call to
Mr Poon’s brother and made a note that the mental health in-reach team should be
invited to the first ACCT case review, in light of his recent admission to hospital.
55. The SO documented in Mr Poon’s electronic prison record that this was Mr Poon’s
first time in prison, and he was apprehensive given his previous profession. The
SO observed Mr Poon appeared calmer after being told he would not be sharing a
cell with anyone. In discussing his suicide attempt, Mr Poon told the SO he was
depressed at the allegations made. He said his head was not in the ‘right place’ but
denied current thoughts of suicide and self-harm. The SO instructed staff to check
Mr Poon once per hour, supported by three recorded conversations daily.
56. Shortly after 8.00pm, Mr Poon arrived on the Vulnerable Prisoner’s Wing (D Wing).
57. At an unknown time the following morning, 14 February, the chaplain, who was an
ACCT assessor, met Mr Poon to complete his initial ACCT assessment. The
chaplain told the investigator that he checked Mr Poon’s electronic prison record
and intended to obtain information from other departments during the first case
review which was due to happen after the assessment.
58. The chaplain told the investigator that the assessment was one of the easiest he
had ever done. He described Mr Poon as friendly, intelligent, self-aware and able
to give a good account of himself. Mr Poon spoke in detail about his previous
suicide attempt. Mr Johnson told the investigator that the assessment stood out as
unusual and he wondered why Mr Poon seemed so cheerful. He asked him about
this, and Mr Poon told him it was because he knew the system and what was going
to happen. He denied thoughts of suicide or self-harm.
59. At around 10.30am, Mr Poon attended his first ACCT case review. An SO chaired
the multidisciplinary review which a safer custody practitioner for Practice Plus
Group, and the chaplain also attended. Mr Poon talked about his recent suicide
attempt which he said he was initially disappointed was not successful. However,
he said these feelings were quickly replaced by hope as his family, specifically his
brother and father, were very supportive, and he realised the impact his suicide
attempt had had on them. During the review, the team identified triggers for the
suicide attempt as his ongoing court case and dismissal from his employment. Mr
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Poon’s care plan reflected that it was his first time in prison, and he was upset due
to the nature of the charges against him. His recent suicide attempt was not
documented and the personal contribution form (where prisoners can document
triggers and what support helps them to cope) was blank.
60. The review noted that Mr Poon had not been in prison before. Mr Poon told them
he had not had an induction or basic skills assessment (which would allow him to
access work, education and other activities) and was keen to engage in purposeful
activity. The SO said he would email the activities department and ask an Insider
(a trusted prisoner who helps other prisoners understand procedures in prison) to
speak to him about the wing regime and to answer any questions.
61. The team observed that Mr Poon articulated his points clearly and showed no
visible signs of distress. Mr Poon said he had no thoughts of suicide or self-harm
as he wanted to be there for his family and did not want to die. Mr Poon asked to
telephone his solicitor as his telephone numbers had not yet been cleared by the
security team. The SO said he would facilitate a call between Mr Poon and his
solicitor (which he did later that afternoon) and told Mr Poon he would facilitate
another welfare call to this brother over the weekend if his numbers had not been
cleared by then.
62. Care plan actions were set for the SO to facilitate welfare calls to Mr Poon’s
solicitor and family. Mr Poon was set actions to apply to add family telephone
numbers to his prison phone account and to collect books and distraction
materials. There was one joint action to ensure the basic skills assessment was
completed. The ACCT remained open, with checks reduced to once every three
hours, supported by two daily conversations. The SO told the investigator that
despite Mr Poon being in prison for less than 24 hours, the team felt he was no
longer in crisis, and he had convinced them that the suicide attempt was a
temporary moment.
63. The SO told the investigator that the team agreed Mr Poon did not present with
any ‘glaring’ risk, and they did not think he was in crisis anymore. However, they
felt it appropriate to keep the ACCT open given his alleged offences, his previous
employment and recent suicide attempt.
64. That day, a social worker from the mental health in-reach team, assessed Mr Poon
as part of the early days in custody pathway. She told the investigator that Mr Poon
was polite and friendly. She said that he appeared calm, and she did not observe
any signs of distress. Mr Poon described his mood as “apprehensive” as the prison
environment was new to him. He said he had not slept well the previous night but
was confident that would improve once he felt more settled. Mr Poon told the social
worker that an ACCT had been opened but repeatedly said that he was not feeling
suicidal or thinking about harming himself. The social worker thought he seemed
concerned about the label of "high suicide risk".
65. At 9.36am on 17 February, a liaison officer in the Offender Management Unit
emailed the Safer Custody Team and the Head of Safety. The email said that
information from the police suggested that, based on his recent suicide attempt
and the psychiatrist’s assessment at Chase Farm Hospital, Mr Poon remained at
very high risk of suicide, and they believed he would attempt suicide again. The
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liaison officer asked that the ACCT should be updated, checks increased to one an
hour and the email shared with three senior officers who worked in the VP Wing.
66. At 10.37am, a Safer Custody administrator forwarded the email to three senior
officers and asked that ACCT checks be increased to hourly. One of the senior
officers told the investigator that he checked his emails daily but did not recall
seeing this one. He said that if he had received an email of that nature, he would
have asked staff to conduct a welfare check. There is no evidence that this was
done.
67. Another senior officer told the investigator that he could not remember if he had
seen the email or if he was working that day. He was sure either of the other two
senior officers would have picked it up. The senior officer said that the Safer
Custody Team usually telephoned the wing to follow up an email if they were
concerned about a prisoner. There is no record that a telephone call took place.
68. A third senior officer told the investigator that he remembered reading the email on
17 or 18 February. He said he did not take action and noted that Mr Poon’s ACCT
case manager had been copied into the email. He said in similar situations, staff
checked with each other that action had been taken, and the prisoner’s ACCT case
manager was aware. The senior officer could not recall speaking to the other
senior officer and took no other action. The frequency of Mr Poon’s ACCT checks
remained once every two hours.
69. On 18 February, a consultant forensic psychiatrist, and a specialty doctor in
psychiatry, discussed Mr Poon at the mental health team meeting. They discussed
Mr Poon’s circumstances, including his previous profession, being on remand for
alleged sex offences and that he had recently been sectioned at Chase Farm
Hospital following a suicide attempt. The team reviewed the social worker’s
assessment from 14 February, and noted Mr Poon did not have a diagnosis of a
mental illness. They made a plan for Mr Poon’s risk of suicide and self-harm to be
managed through the ACCT process, and they agreed to review him at the next
meeting, when they had received the discharge summary from Chase Farm
Hospital. There is no evidence the plan was communicated to wing staff or the
safer custody team.
70. At around 2.00pm on 21 February, Mr Poon attended his second ACCT review. A
senior officer chaired the review and the chaplain attended. As Mr Poon was not
under the care of the mental health team, staff from healthcare were not asked to
attend. They noted that Mr Poon showed no signs of distress and denied thoughts
of suicide or self-harm. He said he had a video call with his brother, but his
telephone numbers had still not been cleared nor had he had his basic skills
assessment. As this remained an outstanding action on Mr Poon’s care plan, the
review concluded the ACCT should remain open, with reduced checks of one each
morning and afternoon, to be supported by three daily conversations. A review
date of 28 February was set.
71. On 25 February, Mr Poon’s brother visited him. He noticed Mr Poon had marks on
his neck. Mr Poon said they were due to him not being able to shower properly. At
around the same time, a prisoner on the same wing as Mr Poon told the
investigator that others had noticed Mr Poon had red marks on his neck. Mr Poon
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told them the marks were from a new prison-issue electric razor. There is no
evidence staff observed or documented any concerns.
72. At around 10.40am on 26 February, an officer met Mr Poon for a keywork session.
Mr Poon told the officer that he was doing well but was slightly bored with the
regime as he was in his cell for 22 to 23 hours each day. He said he spent his time
reading and made full use of any time out of his cell to talk to others. He said he
felt safe on the wing and had no major issues.
73. At around 1.45pm on 28 February, healthcare staff recorded in Mr Poon’s medical
records that they had received the discharge summary from the psychiatrist at
Chase Farm Hospital.
74. At around 2.10pm that afternoon, a senior officer chaired Mr Poon’s ACCT review
as the other senior officer was not working. Mr Poon and the chaplain attended. Mr
Poon said his brother’s telephone number had been added to his prison phone
account and he was trying to get used to the regime. He told the review that he
was staying positive about the charges against him and was hopeful that he would
be granted bail. The chaplain asked Mr Poon how he felt about his next court
hearing on 19 March. Mr Poon said that if bail was not granted, he would carry on
with his legal fight. He denied thoughts of suicide or self-harm. The senior officer
and the chaplain agreed the ACCT would be closed with a post-closure review
date set for 7 March. The senior officer documented the review in Mr Poon’s
electronic prison record. He told the investigator that he did not know why there
was no review documentation in Mr Poon’s ACCT.
75. A prisoner who lived in the cell next to Mr Poon’s told the investigator that at the
end of February 2025, he noticed Mr Poon was not himself as he was not talkative.
Mr Poon told him he was okay but felt lonely. The prisoner said that from that point,
he noticed Mr Poon becoming more withdrawn. He thought Mr Poon may have had
contact with his solicitor at around that time (Mr Poon’s phone records show that
he phoned his solicitor on 3 March).
76. During the first three days of March, wing officers made entries in Mr Poon’s
seven-day ACCT post-closure monitoring form. They wrote that Mr Poon had been
spending time reading in his cell and mixing with his peers on the wing. He said he
was a little bored but felt fine. Staff noted that he was calm. The following four days
were left blank.
77. At around 11.34am on 4 March, two doctors and the Early Days in Custody Mental
Health Lead, discussed Mr Poon at the mental health team meeting. They
reviewed the discharge summary from the psychiatrist, noting that Mr Poon’s risk
of self-harm persisted but his presentation was in keeping with his current
situation. The review concluded that Mr Poon would be discharged from the mental
health in-reach team and his risks of self-harm were to be managed through ACCT
monitoring.
78. At around 5.00pm on 8 March, a senior officer completed an ACCT post-closure
review. The senior officer told the investigator that he spoke to an officer to inform
the review and they both then spoke to Mr Poon for around ten minutes at his cell
door. The senior officer said he was covering two wings (due to a lack of
supervising officers) at the time and he spoke to Mr Poon at the end of the daily
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regime. The senior officer told the investigator that he saw Mr Poon on his bed
watching television and he seemed fine. Mr Poon told him he was in contact with
his brother and was pursuing an appeal. The senior officer said there were no
indications during their interaction that Mr Poon felt suicidal. He recalled that most
of the sections in the daily monitoring form were completed (in fact half were
missing). He said that sometimes these were missing. He did not remember over
half being missing for Mr Poon.
79. At around 10.21am on 11 March, Mr Poon spoke to his solicitor by telephone (legal
calls are confidential and not monitored). He spoke to his brother by telephone
later that evening. The investigator listened to the recording of the call between Mr
Poon and his brother. Mr Poon referenced the call with his solicitor but did not go
into detail. The investigator noted that the call appeared normal and Mr Poon gave
no indications that he was in crisis.
80. A prisoner told the investigator that on 12 March he spoke to Mr Poon at around
4.30pm/5.00pm. Mr Poon told him he was okay. The prisoner said he would bang
on Mr Poon’s wall every evening and he would bang back. He did so as usual
during the early evening, but Mr Poon did not respond.
81. Closed circuit television (CCTV) footage showed Mr Poon collecting his evening
meal and returning to his cell at around 4.37pm. At 4.48pm, Mr Poon was checked
again as officers conducted a roll check (a routine check to ensure prisoners are in
their correct cells).
82. At 9.02pm, while conducting wing welfare checks, an officer checked on Mr Poon
through his cell door observation panel. She had no concerns. Mr Poon did not
activate his emergency cell bell during the night and staff had no reason to check
him.
Events of 13 March 2025
83. The investigator watched CCTV and body-worn video camera (BWVC) footage,
listened to staff radio communications and obtained prison statements and London
Ambulance Service records. The following account is taken from all sources.
84. At around 5.28am, during a routine roll check, an officer looked through Mr Poon’s
cell door observation panel and turned on his night light. In her statement, she
stated she saw what she first thought was Mr Poon sitting on the bottom bunk by
the window. She then noticed his head was drooped and he was hanging with a
ligature around his neck. She immediately radioed a code blue medical emergency
(indicating a prisoner is unconscious or having trouble breathing) and activated her
BWVC.
85. The officer tried to break her sealed pouch (which contains a cell key to be used in
an emergency at night). She shouted to an Operational Support Grade (OSG) for
help. At 5.29am, a senior officer arrived and opened the cell door.
86. The senior officer held Mr Poon’s weight and the officer removed the ligature. They
moved Mr Poon to the floor and the officer began cardiopulmonary resuscitation
(CPR) before another senior officer took over. Two officers arrived within a minute
and took turns in delivering CPR.
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87. At the same time, another officer, who was on G Wing and heard the emergency
code blue on her radio, went to D Wing. She went into Mr Poon’s cell and checked
for a pulse. She was unable to find one.
88. At 5.31am, two nurses arrived with emergency bags. One of the nurses took over
CPR. The nurse told the investigator she noticed Mr Poon’s body was stiff and he
looked blue. She was unable to insert an airway as his jaw was stiff. She thought
he was already dead.
89. At 5.38am, an ambulance arrived with two paramedics. The paramedics went into
Mr Poon’s cell at 5.41am and assessed him. At 5.48am, they declared life extinct.
Contact with Mr Poon’s family
90. At 6.40am on 13 March 2025, the prison appointed a senior officer as family liaison
officer. At 8.35am, the senior officer and an officer visited Mr Poon’s next of kin.
They broke the news of his death and offered support. The prison contributed
toward the cost of Mr Poon’s funeral in line with national policy.
Support for prisoners and staff
91. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners with support following all
deaths in custody. Postvention procedures should be initiated immediately after
every self-inflicted death. Key elements of postvention care include a hot debrief
for staff involved in the emergency response and engaging Listeners (prisoners
trained by the Samaritans to provide confidential peer-support) to identify and
support the prisoners most affected by a death.
92. After Mr Poon’s death, the Head of Safety debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
93. Both nurses who attended the emergency response did not take part in the hot
debrief. The Head of Safety told the investigator that they had already left when he
arrived (he was beginning his shift that morning and both nurses had finished a
night shift). Both nurses said that Practice Plus Group offered them support.
94. The prison posted notices informing other prisoners of Mr Poon’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm; in case they had been adversely affected by Mr Poon’s death.
Post-mortem report
95. The pathologist gave Mr Poon’s cause of death as suspension by ligature.
Inquest
96. At an inquest held between 16 and 26 March 2026, the Coroner concluded that Mr
Poon died by suicide.
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97. The Coroner concluded that the ACCT process was not managed and
implemented properly. The frequency of ACCT checks were inappropriately
reduced and ACCT monitoring stopped too soon. There was insufficient
accountability by staff, evidenced by inconsistent ACCT reviews that lacked
structure, inadequate record keeping, lack of follow-up on agreed actions, lack of
handover between staff and an important email that was not read or followed up
on. There were gaps in staff training and knowledge, and they overly relied on Mr
Poon’s presentation. These failures contributed to Mr Poon’s death because they
led to an inadequate assessment of his risk of suicide.
98. The Coroner found that despite a nurse having formed the correct view that Mr
Poon was dead and that continuing CPR was futile, she took over from prison staff
and continued until paramedics arrived. This was unprofessional, inappropriate
and did not afford Mr Poon dignity or privacy.
99. The Coroner issued a Prevention of Future Deaths report (also known as a
Regulation 28 report), which can be issued following an inquest to highlight
concerns and request action to prevent similar deaths in the future. The report was
directed to the Governor of HMP Pentonville and the Chief Executive of Practice
Plus Group, identifying actions required to prevent similar future deaths.
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Findings
Assessment of risk
100. HMPPS’ Prison Safety Policy Framework sets out the mandatory requirements for
staff on identifying the risks of suicide and self-harm and supporting those at risk to
reduce harm. Assessment, Care in Custody and Teamwork (ACCT) is the Prison
Service case management approach used to support prisoners identified as at risk
of suicide or self-harm.
101. PSI 07/2015 on Early Days in Custody requires that any prisoners arriving with a
suicide and self-harm warning form or any other indication that they may be at risk
of suicide or self-harm are managed in line with safer custody guidance. The policy
requires staff to be alert to the enhanced risk posed by prisoners in particular
circumstances, for example, those in prison for the first time and those with a
history of suicide attempts.
102. Mr Poon arrived at Pentonville with a number of significant risk factors: it was his
first time in prison; he was a former police officer under arrest for serious offences
and had recently been dismissed from the police service and he had been
detained in a mental health hospital less than a month earlier after a suicide
attempt. Court staff appropriately completed a suicide and self-harm warning form
and updated Mr Poon’s escort record to reflect these risk factors.
103. An officer and nurse interviewed Mr Poon when he arrived in reception. The officer
could not recall if he had seen Mr Poon’s suicide and self-harm warning form but
was aware of some suicide risk. Mr Poon denied thoughts of suicide during both
interviews. Despite his calm presentation and denial of thoughts of suicide, the
nurse identified that Mr Poon’s risk factors indicated his risk of suicide was high,
and began ACCT procedures. The nurse was right to begin ACCT procedures,
however we are concerned that the officer who had already processed Mr Poon’s
arrival at Pentonville chose not to initiate ACCT and relied too heavily on Mr
Poon’s demeanour without fully considering his objective risk. We are also
concerned that, despite Mr Poon having significant risk factors to indicate his
suicide risk was high, staff considered that checks of once an hour were sufficient
to support him during his early days in prison. We consider that to be a low level of
support to someone with a high suicide risk.
104. Once the ACCT was opened, a senior officer promptly initiated an immediate
action plan, and a timely assessment and case review was conducted the next
day, with representatives from the early days in custody team and the chaplaincy.
While an assessment took place as required before the review, the chaplain told us
that he did not have all the information he needed and he waited for the review to
complete the assessment. This meant that the review was not as informed as it
might have been. We found that the review lacked sufficient exploration of Mr
Poon’s protective factors such as family support, and did not assess how these
might have mitigated his suicide risk, especially since they were present during his
recent suicide attempt. Additionally, a blank personal contribution plan (where
prisoners can document triggers and what support helps them to cope) indicated a
missed opportunity to engage Mr Poon more meaningfully.
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105. At the same review, the frequency of checks on Mr Poon was reduced from hourly
to once every three hours. We found that this decision was based too heavily on
his presentation (a theme throughout the assessment of risk process), and despite
limited information about his medical history, him having been at the prison for
mere hours, and him being totally unfamiliar to staff. We consider that the
frequency of checks was reduced prematurely, and his care plan was insufficient to
manage the risk posed.
106. Subsequent ACCT reviews on 21 and 28 February were not multidisciplinary and
continued to rely on Mr Poon’s presentation, with insufficient consideration of his
risk factors. We consider that the ACCT was closed prematurely. Due to staffing
pressures, the post-closure review took place in a rushed way at Mr Poon’s cell
door, and overall, we found the post-closure process was managed poorly.
107. Pentonville was unable to provide the ACCT ongoing daily record (where officers
record times of checks and information about a prisoner’s welfare) for 14, 15 and
18 February 2025. For the remaining four days, records showed hourly checks,
despite the care plan stating checks should occur every three hours. There was no
documentation referencing the email sent on 17 February from the safer custody
team to the three senior officers. All told the investigator that they either could not
remember seeing it or had not taken any action. We are unable to establish
whether checks continued to be undertaken hourly and if so, why this was.
However, we found no evidence that this related to the email of 17 February.
108. Overall, we found that the management of Mr Poon’s ACCT was poor. Case
management was inconsistent, and most reviews were not multidisciplinary. While
it was obvious the safer custody practitioner’s role was valued as a link with the
healthcare team and we acknowledge his extensive experience in managing
ACCTs, the presence of a clinician would have offered a clinical perspective of Mr
Poon’s risk of suicide, particularly given his recent discharge from a psychiatric
hospital. Similarly, while the chaplain is respected in his chaplaincy role, staff relied
on him too much to make the reviews multidisciplinary.
109. We conclude that staff relied too heavily on what Mr Poon was telling them. He
was an intelligent, articulate man, who presented as calm. Some staff described
talking to him as like talking to a colleague. We consider that Mr Poon’s
presentation gave staff a false sense of security and they did not keep in mind his
considerable risk factors, that had not changed in the time he spent at Pentonville.
110. The Head of Safety told the investigator that quality assurance checks of ACCTs
generally showed no concern, aside from some missing signatures. HMPPS’ Early
Learning Review recommended that Pentonville should consider a fact-finding
exercise regarding the missing documentation and requested an update by 4 April
2025. We are disappointed that this was not prioritised by the prison and was
completed on 4 August, nearly five months after Mr Poon’s death. The fact-finding
exercise recommended remedial actions to support the ACCT case manager and
temporary oversight of ACCTs they manage for three months. The fact-finding
exercise did not establish what had happened with the missing documentation.
111. We are concerned both by the number of failings identified in the prison’s
management of Mr Poon’s risk of suicide and self-harm risk and the slow response
to the Early Learning Review. Our investigation found failings far beyond one
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officer and the action plan following the fact-finding exercise does not adequately
address these problems.
112. We therefore make the following recommendations:
The Governor should ensure that there is a robust and effective quality
assurance process in place to monitor the quality of ACCT management,
focusing particularly on staff:
• identifying prisoners’ objective risk factors and basing assessment of
risk on them;
• setting meaningful and tailored care plan actions; and
• completing and properly securing all ACCT documentation.
Induction
113. PSI 07/2015 on Early Days in Custody (EDiC) requires Governors to ensure that
all prisoners are given the guidance and information they need about the issues
that are important to them. Prisoners should receive an induction which consists of
two parts, an introduction to custody and a localised introduction specific to each
prison. The first induction should take place within the first five days (reception
counting as day one), with guidance reflecting that best practice is that both take
place on day two. The policy requires prisons to make arrangements for those
whose induction is delayed so that they can obtain information in the interim.
114. At Pentonville, for prisoners who move straight from reception to the Vulnerable
Prisoners’ Wing, induction takes place once a week. When Mr Poon arrived,
induction sessions were run every Wednesday. Mr Poon arrived on a Thursday
evening, and was appropriately identified as suitable for the Vulnerable Prisoner’s
Wing, but that meant he would wait five full days before his induction. A senior
officer told the investigator that he introduced Mr Poon to a Listener who had
previously worked as an Insider to support Mr Poon in the meantime. On 21
February 2025, the senior officer emailed the activities hub to ask for Mr Poon to
be added to the list for a basic skills assessment. There is no evidence the
assessment or induction ever took place.
115. One of Mr Poon’s risk factors was that it was his first time in prison. Although the
prison made arrangements to support Mr Poon in the interim, this period was likely
to have been confusing and upsetting for him. Mr Poon never had a basic skills
assessment which prevented him from engaging in activities that may have
distracted and supported him. It is impossible to say whether a timely induction and
basic skills assessment to enable him to access education and/or work would have
changed the outcome for Mr Poon. However, it is vital that all prisoners, including
those identified as vulnerable, have equal access to a full induction in line with
policy on the early days in custody. While Pentonville tell us they have begun to
make changes to ensure all prisoners receive a timely induction, this has not yet
been fully implemented. We therefore make the following recommendation:
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The Governor should ensure that prisoners located on the Vulnerable
Prisoners’ Wing receive a full induction, including a basic skills assessment,
within the first five days in custody, in line with PSI 07/2015.
Clinical review
116. The clinical reviewer concluded that the healthcare Mr Poon received at
Pentonville was generally equivalent to that which he could have expected to
receive in the community.
117. The clinical reviewer found that the decision not to add Mr Poon to the mental
health caseload was appropriate as he did not require the service. However, they
were concerned about the quality of risk management, communication and
effective working in relation to the ACCT. The clinical reviewer made a number of
recommendations related to ACCT processes, which the Head of Healthcare will
need to address and which we have covered in the section related to assessing Mr
Poon’s risk.
20 Prisons and Probation Ombudsman
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