Rickie Poon
4 Jan 2026 · Coroner Mary Hassell · Inner North London
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate ACCT process management
“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”
2. inadequate training and knowledge gaps
“there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on [the deceased]'s presentation”
3. premature closure of ACCT
“the ACCT was closed too soon”
4. lack of follow‑up on previous resuscitation reports
“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”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“(a) that no Initial ACCT Case Review was held within 24 hours of the Concern & Keep Safe form being completed on 21.6.19;”
This report
“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;”
Closely relatedConfidence 0.90 · high
Earlier report
“there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;”
This report
“- 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;”