George Kyriacos Petrou
PFD Report
Partially Responded
Ref: 2024-0592
461 days overdue · 1 response outstanding
Response Status
Responses
1 of 2
56-Day Deadline
20 Dec 2024
461 days past deadline — 1 response outstanding
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The MATTER OF CONCERN is as follows:
1) Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT. This was contrary to the guidance, policy and procedures in place. While not being placed on an ACCT was not a causative factor in Mr Petrou’s case, it nonetheless raises a risk of death in the future. In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed.
1) Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT. This was contrary to the guidance, policy and procedures in place. While not being placed on an ACCT was not a causative factor in Mr Petrou’s case, it nonetheless raises a risk of death in the future. In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed.
Responses
The Trust commits to implementing a learning event for clinicians focusing on ACCT decision-making, including the message "if in doubt, implement an ACCT". They will also include ACCT importance in future staff inductions and review dilemma cases in senior meetings, with actions concluded by December 2024.
AI summary
View full response
Dear Coroner Potter
Re Inquest touching the death of George Kyriacos Petrou
I am writing following the inquest for George Petrou which concluded on 11th October 2024 and following which you issued a Prevention of Future Deaths report to the Trust. The matters of concern raised were as follows:
Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT. This was contrary to the guidance, policy and procedures in place. While not being placed on an ACCT was not a causative factor in Mr. Petrou’s case, it nonetheless raises a risk of death in the future. In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed.
The Trust acknowledges the concerns raised by the Coroner following the inquest into the death of Mr. Petrou. It is committed to addressing these concerns through a series of actions aimed at preventing future incidents and ensuring the safety of all service users.
The Trust fully recognises the importance and significance of mental health clinicians’ competencies and capabilities regarding ACCT decision making – including this matter in particular - ACCT initiation, but also more broadly ACCT continuation and cessation.
The decision in Mr. Petrou’s case not to implement an ACCT was made because the assessing clinician believed, factoring in clinical and contextual considerations, that the idea of ACCT implementation contradicted the expressed wishes of Mr. Petrou. Accordingly, ACCT initiation was not believed to be required.
In light of the concerns raised by the Coroner, the Trust will continue to assure training standards around ACCT are sustained, will continue to participate in ACCT reviews in
Chair:
Chief Executive:
Better Mental Health. Better Lives. Better Communities. accordance with our operational policy, and will implement a learning event for our Unscheduled Care Team workers and clinicians.
The events leading up to the death of Mr. Petrou will be shared and all clinicians reminded of the support mechanisms in place to aid decision making for cases where the implementation of an ACCT process may contradict the expressed wishes of a service user.
The learning event will focus on the message, ‘if in doubt, implement an ACCT’. The importance of optimising people’s safety through ACCT and our roles and responsibilities, will be included in all future inductions for the Trust’s prison healthcare staff.
Leaders in our services will include ACCT dilemma cases on key meeting agendas for review and consideration by senior clinicians.
These actions will be concluded by close of December 2024.
I hope that this response provides the necessary assurance. Please contact me if you have any queries.
Re Inquest touching the death of George Kyriacos Petrou
I am writing following the inquest for George Petrou which concluded on 11th October 2024 and following which you issued a Prevention of Future Deaths report to the Trust. The matters of concern raised were as follows:
Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT. This was contrary to the guidance, policy and procedures in place. While not being placed on an ACCT was not a causative factor in Mr. Petrou’s case, it nonetheless raises a risk of death in the future. In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed.
The Trust acknowledges the concerns raised by the Coroner following the inquest into the death of Mr. Petrou. It is committed to addressing these concerns through a series of actions aimed at preventing future incidents and ensuring the safety of all service users.
The Trust fully recognises the importance and significance of mental health clinicians’ competencies and capabilities regarding ACCT decision making – including this matter in particular - ACCT initiation, but also more broadly ACCT continuation and cessation.
The decision in Mr. Petrou’s case not to implement an ACCT was made because the assessing clinician believed, factoring in clinical and contextual considerations, that the idea of ACCT implementation contradicted the expressed wishes of Mr. Petrou. Accordingly, ACCT initiation was not believed to be required.
In light of the concerns raised by the Coroner, the Trust will continue to assure training standards around ACCT are sustained, will continue to participate in ACCT reviews in
Chair:
Chief Executive:
Better Mental Health. Better Lives. Better Communities. accordance with our operational policy, and will implement a learning event for our Unscheduled Care Team workers and clinicians.
The events leading up to the death of Mr. Petrou will be shared and all clinicians reminded of the support mechanisms in place to aid decision making for cases where the implementation of an ACCT process may contradict the expressed wishes of a service user.
The learning event will focus on the message, ‘if in doubt, implement an ACCT’. The importance of optimising people’s safety through ACCT and our roles and responsibilities, will be included in all future inductions for the Trust’s prison healthcare staff.
Leaders in our services will include ACCT dilemma cases on key meeting agendas for review and consideration by senior clinicians.
These actions will be concluded by close of December 2024.
I hope that this response provides the necessary assurance. Please contact me if you have any queries.
Report Sections
Investigation and Inquest
On 19 March 2021, an investigation was commenced into the death of George Kyriacos Petrou, then aged 56 years. The investigation concluded at the end of an inquest heard by me between 30 September 2024 and 11 October 2024.
The inquest concluded with a short-form conclusion of suicide. The medical cause of death was:
1a partial suspension
The inquest concluded with a short-form conclusion of suicide. The medical cause of death was:
1a partial suspension
Circumstances of the Death
George Petrou was remanded in custody on 21 March 2019 at HMP Pentonville, pending a trial at the Crown Court. He was convicted of multiple offences in late 2020. On 26 February 2021, Mr Petrou was sentenced to 22 years’ imprisonment via a video link hearing. Mr Petrou left the hearing prior to hearing his sentence being handed down by the Judge.
Throughout 2019 and 2020, Mr Petrou had been placed on an ‘ACCT’ (suicide prevention measures) on four separate occasions. He had profound mental health concerns dating back many decades, which included a long history of depression, previous self-harm and past attempts at suicide.
During his time in HMP Pentonville, there was no evidence that Mr Petrou had self-harmed or made previous attempts at suicide. He was received care in relation to his physical health and was under the care of the mental health in-reach team (provided by Barnet, Enfield and Haringey Mental Health NHS Trust (the Trust)).
Receiving a long custodial sentence was a potential matter of concern for George Petrou. He was seen by staff from the Trust on the day of his sentencing hearing and the following day.
Mr Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021, having partially suspended himself by ligature in the bathroom of his cell.
Throughout 2019 and 2020, Mr Petrou had been placed on an ‘ACCT’ (suicide prevention measures) on four separate occasions. He had profound mental health concerns dating back many decades, which included a long history of depression, previous self-harm and past attempts at suicide.
During his time in HMP Pentonville, there was no evidence that Mr Petrou had self-harmed or made previous attempts at suicide. He was received care in relation to his physical health and was under the care of the mental health in-reach team (provided by Barnet, Enfield and Haringey Mental Health NHS Trust (the Trust)).
Receiving a long custodial sentence was a potential matter of concern for George Petrou. He was seen by staff from the Trust on the day of his sentencing hearing and the following day.
Mr Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021, having partially suspended himself by ligature in the bathroom of his cell.
Copies Sent To
Hudgell Solicitors ( )
Practice Plus Group
primary care provider at HMP Pentonville
Ministry of Justice / HMP Pentonville
Care Quality Commission
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Require effective communication among healthcare professionals to avoid conflicting patient advice
Bristol Heart Inquiry
Conflicting mental health care plans
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.