George Petrou

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Independent investigation into
the death of Mr George Petrou,
a prisoner at HMP Pentonville,
on 1 March 2021
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, 2024
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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.
The office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr George Petrou was found hanged in his cell at HMP Pentonville on 1 March 2021. He
was 56 years old. I offer my condolences to Mr Petrou’s family and friends.
On 26 February 2021, Mr Petrou was sentenced to 22 years in prison, by video link.
Despite Mr Petrou telling staff that he would rather die than spend a long time in prison, no
one started suicide and self-harm prevention measures (known as ACCT). This was a
missed opportunity to put support in place for Mr Petrou.
Although healthcare staff reviewed Mr Petrou after he was sentenced, our investigation
found that Pentonville did not have a standard procedure for assessing whether there had
been a change in risk for prisoners after attending video link court hearings.
My investigation also found that Mr Petrou did not have the support of a key worker as he
should have done. I am also concerned that healthcare staff did not realise until 25
February 2021, that Mr Petrou had not been prescribed his antidepressant medication
since mid-November 2020.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman November 2021
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Contents
Summary ........................................................................................................................ 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 14
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Summary
Events
1. On 21 March 2019, Mr George Petrou was remanded in custody, charged with rape
and other sexual offences, and sent to HMP Pentonville.
2. Staff supported Mr Petrou using suicide and self-harm prevention measures (known
as ACCT) on four occasions during his time at Pentonville. The last period of ACCT
monitoring ended in August 2020.
3. Mr Petrou was under the care of the prison’s mental health team throughout his
time at Pentonville. They noted that he would need close monitoring around the
time of his trial as he said that, if convicted, he would leave prison ‘in a body bag’.
During his trial, he said that he would rather die than spend a long time in prison.
4. On 26 February 2021, Mr Petrou was sentenced to 22 years in prison. He attended
court by video link. Following sentencing, he was reviewed by healthcare staff, but
they did not start ACCT procedures. Mr Petrou said that he did not want to be on
an ACCT as the checks would interfere with his sleep, which would make him more
anxious.
5. On 1 March, at around 8.55am, an officer arrived at Mr Petrou’s cell to unlock him
for medication. The officer found Mr Petrou hanging from the window in the toilet.
The officer radioed a medical emergency code. Prison and healthcare staff quickly
responded. They did not attempt resuscitation as it was clear Mr Petrou was dead.
Paramedics attended and at 9.23am confirmed he had died.
Findings
6. We found that, overall, staff managed the ACCT procedures well. However, we are
concerned that staff did not start ACCT monitoring after Mr Petrou was sentenced,
given his clear risk factors for suicide.
7. We are concerned that there is no evidence prison staff had any meaningful
interaction with Mr Petrou after he was sentenced by video link. There is nothing in
his prison record about the hearing or sentence. Although healthcare staff met with
Mr Petrou shortly after his sentencing and the next day, nobody met with him the
day before he died, as they should have done.
8. The clinical reviewers concluded that the physical and mental health care Mr Petrou
received was good and equivalent to that which he could have expected to receive
in the community. However, they noted that staff did not realise until 25 February
2021, that he had not been prescribed his antidepressant medication since mid-
November 2020.
9. We found that Mr Petrou did not have a key worker from January 2021 as he should
have done. This was a missed opportunity to provide additional support to him,
particularly around the time of his sentence.
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10. An intelligence report, submitted in December 2020, that said Mr Petrou might be
being bullied by another prisoner on the wing, was not actioned. Staff did not refer
Mr Petrou to the Safety Intervention Meeting, and nobody considered violence
reduction measures.
Recommendations
• The Governor and Head of Healthcare should ensure that staff assess prisoners’
risk of suicide and self-harm based on their risk factors and not solely on their
presentation and what the prisoner tells them.
• The Head of Healthcare should ensure that staff see prisoners at the agreed
frequency, in line with their care or support plan.
• The Governor and Head of Healthcare should ensure that following a court
appearance by video link:
• the prisoner’s NOMIS record is updated with details of the hearing and the
outcome; and
• staff should speak to the prisoner and consider whether their risk to
themselves has changed.
• The Director General of HMPPS should review PSO 3050 and PSI 07/2015 to
ensure that prisoners who attend court by video link are assessed for their risk of
suicide and self-harm and seen by healthcare staff in the same way as prisoners
attending court in person.
• The Head of Healthcare should review the systems for medicines management to
identify systemic issues with prescribing.
• The Governor should ensure that during a restricted regime, key work is delivered
in line with the Exceptional Delivery Model.
• The Governor should ensure that staff:
• investigate suspected or alleged bullying in line with the prison’s violence
reduction policy;
• support victims of bullying by making CSIP referrals; and
• refer cases to the Safety Intervention Meeting where appropriate.
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The Investigation Process
11. 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.
12. The investigator obtained copies of relevant extracts from Mr Petrou’s prison and
medical records.
13. NHS England commissioned a clinical reviewer to review Mr Petrou’s clinical care
at the prison.
14. On 8 April, the investigator interviewed six members of staff with the clinical
reviewer. In addition, the investigator interviewed five members of staff and two
prisoners. All interviews were conducted by video or telephone due to the COVID-
19 restrictions.
15. We informed HM Coroner for London Inner North of the investigation. We have
sent the Coroner a copy of this report.
16. We contacted Mr Petrou’s brother and daughter to explain the investigation and ask
if they had any issues they wanted the investigation to consider. Mr Petrou’s family
wanted to know:
• Were Pentonville aware of Mr Petrou’s mental health diagnosis when he
arrived at Pentonville and how was this managed?
• What medication was Mr Petrou prescribed and whether this was stopped
before his court appearance?
• Why Mr Petrou was not admitted to a mental health facility or located in the
prison healthcare unit?
• How frequently was Mr Petrou observed during his time in Pentonville and
did this frequency increase after his court hearing, given his history of suicide
attempts?
• Was the prison aware Mr Petrou suffered from flashbacks due to his
experience of childhood sexual abuse?
• Why did staff not identify that Mr Petrou was not eating, losing weight and did
not go out on exercise for fresh air?
• Why was Mr Petrou not monitored after his sentence, despite a telephone
call to the safer custody team expressing extreme concern for his safety?
• Why did Mr Petrou live in a single cell with a toilet door?
• Why did Pentonville not listen to Mr Petrou’s telephone calls in the weeks
before he died and identify that he was suicidal?
We have answered their questions in this report and in the clinical review.
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17. Mr Petrou’s family received a copy of the initial report. Mr Petrou’s daughter
responded, via her legal representative, and said the detail of her contact with the
prison raising concerns about her father’s risk on 27 February was inaccurate, as
she had also spoken to someone in the Control Room and was assured that the
prison would do what they could to keep her father safe and check on him regularly.
(The investigator found no evidence of this contact.)
18. The prison also received a copy of the report and did not identify any factual
inaccuracies.
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Background Information
HMP Pentonville
19. HMP Pentonville is a local prison in London that holds around 1,200 prisoners. The
prison primarily serves the courts of north and east London. Practice Plus Group, in
partnership with Enfield and Haringey Mental Health Trust, provides healthcare
services.
HM Inspectorate of Prisons
20. HM Inspectorate of Prisons (HMIP) carried out an unannounced inspection of
Pentonville in April 2019. Inspectors said that ACCT support processes remained
weak and were generally poorly managed. They reported that many ACCT
caremaps were inadequate, that there was no continuity of case ownership and that
there was limited multidisciplinary involvement in case reviews.
21. Inspectors reported that about a third of prisoners said they felt unsafe and that
levels of violence were high. They said that investigations were currently not being
completed and the Prison Service’s new case management approach to managing
perpetrators of violence and supporting victims (CSIP) had not yet been introduced.
22. Inspectors reported that there was sound governance of healthcare, that staffing
levels and skills mix were sufficient, that there had been demonstrable learning from
deaths in custody and regular sharing of health information between specialist
teams at the health and wellbeing referral meetings.
23. Reporting on previous deaths at the prison, inspectors raised concerns that while
PPO recommendations about healthcare had been met, most of the other PPO
recommendations had not been achieved.
24. HMI Prisons Independent Reviews of Progress (IRPs) inspectors returned to
Pentonville in January 2020. Inspectors reported that progress had been
disappointingly slow and found that little had been done to respond to a very poor
inspection report in 2019, until a few days before the IRP itself.
Independent Monitoring Board
25. 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 2020, the IMB reported
that incidents of self-harm had risen over the reporting year. The Board noted the
quality of the ACCT process had improved, but there was still a need to ensure all
relevant participants were included in reviews.
26. The IMB noted that violence reduction measures (CSIP) could not be properly
assessed as safer custody meetings had not been held and the information was not
available.
27. The IMB found that some aspects of staff culture were obstructing positive
engagement with and care for prisoners. However, the key worker scheme had had
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a positive impact, including on the management of the ACCT process, but key
worker provision had been severely impacted due to COVID-19.
28. The IMB reported that healthcare waiting times were equivalent to the community.
The wellbeing centre received a national award for best team in clinical services .
Previous deaths at HMP Pentonville
29. Mr Petrou’s death was the ninth at Pentonville since March 2019. Of the previous
deaths, five were self-inflicted, one was drug related and two were from natural
causes. We have previously made recommendations on assessment of risk of
suicide and self-harm, the key worker scheme and investigating bullying allegations.
Assessment, Care in Custody and Teamwork (ACCT)
30. ACCT is the Prison Service care-planning system used to support prisoners 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. All
decisions made as part of the ACCT process and any relevant observations about
the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011 on Safer Custody.
Key worker scheme
31. HMPPS’s policy document, Managing the Custodial Sentence Policy Framework,
set out the minimum requirements needed to case manage those in custody from
reception to the end of post-release supervision. This included the gradual
introduction of the key worker role from September 2018, replacing the previous
system of personal officers. Requirements of the scheme include:
• All prisoners in the male closed estate must be allocated to a key worker
whose responsibility is to engage, motivate and support them throughout the
custodial period.
• All prison officers who work on a residential unit will be allocated a maximum
of six prisoners. Governors must ensure that time is made available for an
average of 45 minutes per prisoner per week for delivery of the key worker
role, which includes individual time with each prisoner.
• Key workers will record meetings, discussions and any progress that has
been made on NOMIS in a detailed manner. These notes will be regularly
checked as part of on-going quality assurance, so it is important that they are
sufficient.
32. Key work was suspended on 24 March 2020 due to the COVID-19 pandemic. On
12 May, the Prison Service issued an Exceptional Delivery Model (EDM) for key
work which was introduced nationally and provided a framework of principles within
which establishments must operate but was for local determination on how to
deliver this safely. The EDM set out the expectations of contact and that all
contacts and concerns should be recorded on a prisoner’s record. The EDM
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identified priority prisoner groups for whom it was recommended that key work
should continue, which included prisoners at risk of suicide or self-harm.
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Key Events
33. On 21 March 2019, Mr George Petrou was remanded in prison custody, charged
with rape and other sexual offences, and sent to HMP Pentonville. This was his
first time in prison.
34. Mr Petrou had overdosed the day before he was remanded and had been on
constant watch while at court. Prison staff started suicide and self-harm prevention
measures (known as ACCT) when he arrived at Pentonville. They liaised with Mr
Petrou’s mental health team in the community who said that Mr Petrou had spent
time in a psychiatric hospital and had a working diagnosis of psychotic depression,
anxiety, adjustment disorder and traits of emotionally unstable personality disorder
(EUPD).
35. On 28 May, during an ACCT review, Mr Petrou said, ‘If I get convicted, I believe I
have not done anything wrong, write this down, I will be taken out of prison in a
body bag’. Mr Petrou spent time under constant supervision and was regularly
reviewed by the prison’s mental health team.
36. On 30 May, Mr Petrou was found guilty on some of the charges. The jury was
unable to reach a decision on a number of other charges. He remained in custody
awaiting sentence and a decision by the Crown Prosecution Service about whether
to pursue a re-trial. Staff stopped ACCT monitoring on 31 July. Mr Petrou
continued to be under the care of the prison’s mental health team. They noted that
an ACCT and increased observations would be needed around the time of Mr
Petrou’s trial.
37. Staff monitored Mr Petrou under ACCT from 4 to 17 September, after he scored
highly on two questionnaires that assess the severity of depression and anxiety,
and again from 8 October to 4 November, after his partner died.
2020
38. On 20 January 2020, Mr Petrou’s re-trial started. However, on 19 March, his case
was adjourned after he developed COVID-19 symptoms. Over the next few
months, Mr Petrou slowly recovered. His mental health continued to be reviewed
and monitored.
39. On 26 May, Mr Petrou said that he had been raped by a cellmate in October 2019
but did not wish to take the matter further. Staff gave him helpline numbers and told
the prison safeguarding team. (Mr Petrou was later interviewed by the police, but
there were no criminal charges). Mr Petrou also said he was being bullied by his
current cellmate. Staff moved him to a single cell.
40. On 28 June, Mr Petrou was placed on the basic level of the incentives and earned
privileges scheme (IEP) as he refused to have a cellmate, but the next day he
agreed to have a cellmate and reverted to the standard regime. On 1 August, Mr
Petrou was made enhanced on the IEP scheme.
41. On 14 August, staff started ACCT monitoring after Mr Petrou told a nurse that he
was having flashbacks of the alleged sexual assault which meant he had trouble
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sleeping. He was moved to a single cell. He said he felt safer and more settled but
also lonely. Staff stopped ACCT monitoring on 20 August.
42. On 27 August, a supervising officer held a post-closure ACCT review with Mr
Petrou. He noted that Mr Petrou said that staff had been ‘fantastic’ but that he
wished he had been in a single cell much earlier. (Other than a couple of brief
entries regarding Mr Petrou shielding from the COVID-19 virus in January 2021, this
is the last meaningful entry on his prison record before he died.)
43. On 1 September, Mr Petrou’s trial started. A consultant psychiatrist and a mental
health nurse reviewed Mr Petrou. They noted that his trial was imminent and that
he should remain on an ACCT (they were not aware that the ACCT had been
closed as it was not recorded in Mr Petrou’s medical record). They contacted the
wing supervising officer to recommend that Mr Petrou should not be in a single cell.
44. On 29 September, a prison GP and the mental health nurse reviewed Mr Petrou.
They noted the ACCT had been closed, despite the earlier note that ACCT
measures should be in place during his trial, but that Mr Petrou had said he would
prefer not to be on an ACCT as this would ‘make him feel more suicidal’. The
mental health team saw him regularly during his trial.
45. On 20 and 21 October, Mr Petrou was convicted of further offences. On 22
October, the mental health nurse saw Mr Petrou and noted that his mood was low,
and that he was finding the court proceedings depressing. The next day Mr Petrou
told the nurse that the trial had concluded, and he was awaiting the verdict. Mr
Petrou said he did not want to be on an ACCT.
46. On 9 November, a psychiatrist met with Mr Petrou and discussed his court hearing.
Mr Petrou said he was hoping to get a short sentence. The psychiatrist noted he
thought monitoring would be needed at the point of sentence due to the potential
increase in risk of self-harm.
47. On 17 November, a prison GP and the mental health nurse reviewed Mr Petrou.
They did not record any concerns but noted that increased vigilance at the time of
sentencing should be considered along with starting ACCT measures.
48. On 8 December, a prison officer on C Wing submitted an intelligence report which
said that a prisoner on the wing may have been bullying prisoners, including Mr
Petrou, for money and their canteen (purchases from the prison shop). There is no
evidence that any action was taken.
2021
49. On 13 January 2021, a psychiatrist saw Mr Petrou. He recorded that Mr Petrou
thought he would not be given a long custodial sentence. He noted his sentencing
date of 25 February (though it was 26 February) and that the plan should be to
closely monitor Mr Petrou around this time.
50. On 26 January, a forensic social worker with the mental health in-reach team took
over Mr Petrou’s care. He noted that Mr Petrou said he was anxious about
sentencing but did not have any thoughts of suicide or self-harm. He set reviews
for every two weeks, scheduled a psychiatric review for 17 February and recorded
that Mr Petrou should be assessed again shortly after he was sentenced. On 28
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January, he completed a review of Mr Petrou’s CPA (Care Programme Approach –
used to support those with complex mental health needs) and scheduled the next
review in three months.
51. On 9 February, the forensic social worker met with Mr Petrou and noted in his
medical record that he said, ‘I'd rather die than spend a long time in prison’. He
also noted that Mr Petrou said he had no current thoughts of suicide or self-harm.
52. On 16 February, Snaresbrook Crown Court contacted the Offender Management
Unit (OMU) at Pentonville to tell them that Mr Petrou was to appear in court by
video link at 2.00pm on 26 February.
53. The same day, a prison GP and the forensic social worker reviewed Mr Petrou’s
care. Two weekly reviews with the mental health in-reach team continued and they
noted it was necessary for increased vigilance around the time of sentencing and
that an ACCT would be opened if necessary.
54. On 17 February, a psychiatrist completed the scheduled psychiatric review. He
recorded that there were no new concerns about Mr Petrou’s physical or mental
health. He noted that Mr Petrou was in a single cell, choosing to spend much of his
time in there. They discussed Mr Petrou’s impending court appearance on 26
February for sentencing. Mr Petrou told him that he was aware he could receive a
long custodial sentence, but that his legal team had lodged an appeal, which he
was pleased about. Mr Petrou said he had no thoughts of self-harm and when
asked how he would manage if he was given a long sentence, he said he would not
harm himself, and would tell staff of his thoughts.
55. The psychiatrist prescribed Mr Petrou with a five-day course of sleeping tablets
(zopiclone). He also noted that the mental health in-reach team should review Mr
Petrou before his sentence, discuss the management plan with prison staff and
start ACCT measures if necessary.
56. On 24 February, the forensic social worker met with Mr Petrou, who told him that
his sentencing date was in two days’ time and would be by video link. He noted
that Mr Petrou had some anxiety about being sentenced, but there were no
concerns about his mental state, and he said he had no thoughts of suicide or self-
harm. He told Mr Petrou that he had arranged for colleagues from the in-reach
team to visit him following sentencing.
57. On 25 February, a healthcare assistant sent an email to the health and wellbeing
team (HWB). She said that while having a thyroid blood test, Mr Petrou said that he
had been feeling quite low and was having ‘stupid thoughts’ but did not intend to act
on them. She gave him information on the HWB group and Mr Petrou said he was
interested in engaging with the team and eager to speak to someone about his
feelings. She noted that Mr Petrou was no longer receiving his antidepressant
medication (citalopram) and sent a task for the GP to review his medication.
58. The same day, the forensic social worker spoke with a SO (Supervising Officer),
one of the managers on C Wing. He told him that Mr Petrou was due to be
sentenced, which could increase his risk of suicide and self-harm. He told the SO
that the in-reach team would review Mr Petrou after sentencing and over the
weekend. They agreed to share this information with the other wing manager, and
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if there were any concerns then ACCT measures would start. While this discussion
is recorded in Mr Petrou’s medical record, there is nothing recorded on his prison
record or the wing observation book.
59. Mr Petrou maintained contact with his family throughout his time at Pentonville. All
prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. The investigator listened to the calls
made by Mr Petrou in the days before he died. At 9.59pm, he called his brother
and they spoke for 87 minutes. There was nothing in the call to suggest Mr Petrou
was in crisis.
26 to 28 February
60. On the morning of 26 February, Mr Petrou went to a health and wellbeing (HWB)
meeting. A nurse noted that the GP would review Mr Petrou’s medication, and he
would be assessed by the in-reach team later that day.
61. The time of Mr Petrou’s court appearance is not recorded, although earlier contact
from Snaresbrook Crown Court to Pentonville indicated that the hearing would start
at 2.00pm. Mr Petrou was sentenced to 22 years imprisonment, by video link.
There is nothing about his court appearance or the outcome recorded on either Mr
Petrou’s prison record or the wing observation book. (In the Judge’s summary he
noted that Mr Petrou had declined to attend court the previous week and had left
the hearing before sentence was passed.)
62. A SO said he was at his desk when an officer from C Wing told him that Mr Petrou
had appeared in court, by video link, and that when he saw his family, he was upset
and so left the room. (He could not remember the name of the officer, but we know
who the officer was.) The officer had not been given any details about the court
appearance or sentence, but had spoken to Mr Petrou, who assured her he was
fine. We do not know when or who informed Mr Petrou of his sentence.
63. At 2.40pm, a prison GP met with Mr Petrou to review his medication and mood
following sentence. Mr Petrou told the GP that he had been feeling low recently
and had only just realised he had not been prescribed his antidepressant
medication.
64. At 4.06pm, a nurse from the Inreach team went to see Mr Petrou in his cell. The
nurse noted that Mr Petrou had panicked when he got to the video link room and
did not wait to hear the sentence, so left. Mr Petrou told the nurse that he had not
thoughts of suicide or self-harm and did not want an ACCT to be opened as he
would not be able to sleep if checked regularly and this would increase his anxiety.
Mr Petrou asked about his antidepressant medication. The nurse spoke to wing
staff and asked them to check on Mr Petrou and provide support if his anxiety
increased. The nurse told Mr Petrou he would visit him the next day.
65. At 4.38pm, Mr Petrou made his final telephone call, to his solicitor, which lasted 49
seconds (the call was not recorded because legal calls are confidential).
66. At 4.46pm, a prison GP spoke to a psychiatrist, who noted Mr Petrou’s
antidepressant medication had been stopped by accident and re-prescribed his
citalopram.
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67. Prisoner A on C Wing said he had known Mr Petrou for around 6-7 weeks. He said
they met regularly, were both Greek Orthodox and used to pray and drink coffee
together. He said when he served Mr Petrou’s meal and asked how his sentencing
had gone, Mr Petrou told him it had been delayed because of COVID-19. He said it
was not a long conversation, but Mr Petrou seemed no different to his normal self.
68. On the morning of 27 February, a nurse from the mental health in-reach team met
with Mr Petrou. Mr Petrou told her that he did not know the outcome of the
sentencing hearing and would contact his solicitor. Mr Petrou told the nurse that his
brother was providing support, that he was pleased his antidepressant medication
had been prescribed and that he had no thoughts of suicide or self-harm. The
nurse described Mr Petrou’s mood as ‘bright’.
69. There is no evidence that anyone from the mental health in-reach team met with Mr
Petrou on 28 February.
70. A SO said that he spoke with Mr Petrou in the morning while unlocking prisoners for
exercise, which Mr Petrou politely refused. The SO said Mr Petrou was sitting at
his desk writing a letter and he had no concerns about him.
71. Prisoner A said he last saw Mr Petrou at around 4.00pm, when he took his meal to
his cell. Mr Petrou was sitting at his desk writing a letter. There was nothing that
caused concern. A SO said he spoke to Mr Petrou at around 4.50pm at the
medication hatch. Mr Petrou told him to have a nice evening and that he would see
him tomorrow. The SO had no concerns.
Monday 1 March
72. On 1 March at 5.40am, the night duty officer completed her early morning roll check
(a count of all prisoners). She looked into Mr Petrou’s cell through the observation
panel and saw what she believed to be him lying in bed asleep and continued the
rest of her count.
73. Two officers attended a morning briefing around 7.45am, before starting to unlock
prisoners for their medication. They arrived at Mr Petrou’s cell around 8.55am.
Officer A unlocked the door, and he could see what he thought was Mr Petrou still
in bed. Officer B entered and said there was a smell of body fluids. When he
shook Mr Petrou to wake him up, he discovered a dummy (made up of filled plastic
bags) had been left in the bed. The officers activated their body worn video
cameras (BWVC). Officer B went to the toilet area, where he discovered Mr Petrou
was suspended by a ligature attached to the window of the cell.
74. Officer A radioed a medical emergency code blue (used when a prisoner is not
breathing which alerts healthcare staff and tells the control room to call an
ambulance immediately) and shouted for staff to lock prisoners back into their cells.
A SO responded and assisted both officers in cutting the ligature and moving Mr
Petrou to the floor. They did not begin cardiopulmonary resuscitation as it was
evident Mr Petrou was already dead. A nurse responded to the code blue and said
that Mr Petrou was stiff, his blood had pooled, and his pupils were fixed and dilated,
all signs Mr Petrou had been dead for some time.
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75. The London Ambulance Service confirmed they received a request for an
emergency ambulance at 9.00am and arrived at Mr Petrou’s cell at 9.06am.
Paramedics completed their assessments and at 9.23am recorded that Mr Petrou
had died.
Information after Mr Petrou’s death
76. Officers found a suicide note in Mr Petrou’s cell dated Sunday 28 February which
said, ‘My minds exhausted. Gone to find my mum. *9.30pm* Goodbye world. DNR
– Do Not Resuscitate’. Mr Petrou had also left some belongings in a bag and a
note which read; ‘Kev you helped me loads. Thank you xx’.
77. Prisoner B who lived on C Wing said Mr Petrou told him that he had walked out of
his video link court appearance and he could tell he was upset. He said he told an
officer (name not known) that he was concerned about Mr Petrou and a female
officer to ‘keep an eye’ on him.
78. On 1 March, Safer Custody staff discovered that Mr Petrou’s daughter had left a
voicemail message on Saturday 27 February at around 1.30pm, which said she was
concerned for her father’s welfare, that he had mental health issues and had
previously felt suicidal.
Contact with Mr Petrou’s family
79. On 1 March, the prison appointed a family liaison officer (FLO). While under normal
circumstances next of kin should, wherever possible, be informed of a death in
person by a FLO, Government advice at the time prohibited all but essential travel
and required social distancing to prevent the spread of the COVID-19 virus. At
around 11.00am, the FLO informed Mr Petrou’s brother of his death by telephone
and later spoke to Mr Petrou’s daughter. The prison provided ongoing support and
contributed towards the costs of Mr Petrou’s funeral, which was held on 26 April, in
line with national policy.
Support for prisoners and staff
80. After Mr Petrou’s death, a senior prison manager debriefed all 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.
81. The prison posted notices informing other prisoners of Mr Petrou’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by the death. Prisoner A said
he felt very well supported.
Post-mortem report
82. We have not yet received the post-mortem or toxicology reports from the Coroner.
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Findings
Assessment and management of Mr Petrou’s risk of suicide and self-
harm
83. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures, known
as ACCT, that staff must follow when they identify prisoners at risk of suicide and
self-harm.
84. Mr Petrou was supported under ACCT on four occasions at Pentonville. We found
that he received a good level of support from both healthcare and prison staff during
those periods.
85. We are concerned, however, that Mr Petrou was not being monitored under ACCT
when he died. In November 2020, healthcare staff noted that increased vigilance
would be needed around the time Mr Petrou was sentenced and an ACCT would
need to be considered. Once staff were aware of the scheduled sentencing date,
26 February 2021, there were further notes that Mr Petrou would need to be closely
monitored around that time. On 9 February, Mr Petrou told staff he would rather die
than spend a long time in prison. On 25 February, Mr Petrou told a healthcare
assistant that he had been feeling quite low and was having ‘stupid thoughts’,
though he said he did not intend to act on them.
86. We are very surprised that after Mr Petrou was sentenced to 22 years in prison,
healthcare staff did not open an ACCT. Mr Petrou told them that he did not want an
ACCT to be opened as the checks would interrupt his sleep, which would increase
his anxiety. We do not consider this was a valid reason not to open an ACCT. All
the indications were that Mr Petrou was at a very high risk of suicide if he was
sentenced to a long time in prison. Staff missed an opportunity to put support
measures in place. We recommend:
The Governor and Head of Healthcare should ensure that staff assess
prisoners’ risk of suicide and self-harm based on their risk factors and not
solely on their presentation and what the prisoner tells them.
87. We note that healthcare staff saw Mr Petrou after he was sentenced on 26
February, and on 27 February, but they did not see him on 28 February. This was
despite a record that someone should see him every day. We recommend:
The Head of Healthcare should ensure that staff see prisoners at the agreed
frequency, in line with their care or support plan.
Court appearance
88. PSI 07/2015, Early days in custody, says that there must be arrangements in place
to assess prisoners whose status or demeanour may have changed after a court
appearance by video link. Prison Service Order (PSO) 3050, Continuity of
Healthcare for Prisoners, says that prisons must have procedures in place so that
prisoners who have attended court by video link who request help, or who are
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identified as needing help, from healthcare staff, are told how to access it and are
able to receive it in an appropriate timeframe.
89. While we accept that Mr Petrou was assessed by healthcare staff following his
video link appearance on 26 February (as this had been pre-arranged when
healthcare staff found out when he was due to be sentenced), there appeared to be
no standard procedure for prison staff to assess whether a prisoner’s status or
demeanour had changed or whether they might need to see healthcare staff after a
video link court appearance. There was nothing noted in Mr Petrou’s prison record
about the hearing on 26 February or the outcome.
90. After Mr Petrou’s death, Pentonville introduced a proforma for video link staff to
record information after a hearing. The proforma prompts staff to contact the duty
nurse if there has been a change in the prisoner’s status, or if they are sentenced,
and to make an entry on the prisoner’s record and inform the Offender Management
Unit (OMU). While this is an improvement, it still relies too heavily on the prisoner
providing accurate information.
91. The OMU manager told us that she has not been able to establish what time the
OMU received details of Mr Petrou’s sentence but was told by the video link clerk
that the warrant from Snaresbrook Crown Court had been received around 4.00pm
on 26 February. She said that since Mr Petrou’s death, she has met with senior
managers who are working on improving the process of sharing information and
recognising when risk to a prisoner may increase.
92. We recommend:
The Governor and Head of Healthcare should ensure that following a court
appearance by video link:
• the prisoner’s NOMIS record is updated with details of the hearing and
the outcome; and
• staff should speak to the prisoner and consider whether their risk to
themselves has changed.
93. An increasing number of prisoners are being sentenced by video link, especially
during the COVID-19 pandemic. As they do not leave the prison, they are not
subject to the standard screening procedures that they would have when returning
to the prison and passing through reception. Prisoners passing through reception
would not only be assessed for risk of suicide and self-harm but also those with a
change in status, including those who have been sentenced, would be referred to
healthcare staff. This does not happen for video link hearings. We therefore
consider that national guidance should be reviewed to ensure that processes are in
place for assessing prisoners at risk of suicide and self-harm after a court
appearance by video link. We make the following recommendation:
The Director General of HMPPS should review PSO 3050 and PSI 07/2015 to
ensure that prisoners who attend court by video link are assessed for their
risk of suicide and self-harm and seen by healthcare staff in the same way as
prisoners attending court in person.
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Clinical care
94. The clinical reviewer concluded that, overall, Mr Petrou’s clinical care was of a good
standard and equivalent to that which he could have expected to receive in the
community. The clinical reviewer noted that Mr Petrou’s mental health care was
well managed and that he received appropriate care when he had COVID-19
symptoms.
Antidepressant medication
95. On two occasions, Mr Petrou’s antidepressant medication (citalopram) was not
prescribed. On 25 June 2019, it was discovered that Mr Petrou had not been
prescribed citalopram for around two months. On 25 February 2021, it was
discovered that the medication had not been prescribed since mid-November 2020.
96. The clinical reviewer found these were oversights and not a clinical decision to stop
antidepressant medication. Mr Petrou was regularly reviewed by the mental health
team during both periods and while there was no significant change, Mr Petrou did
speak of increased anxiety which could possibly be attributed to not receiving his
medication. We recommend:
The Head of Healthcare should review the systems for medicines
management to identify systemic issues with prescribing.
Key work scheme
97. Key work was formally suspended across the prison estate on 24 March 2020 due
to the COVID-19 pandemic. On 12 May, the Prison Service issued an Exceptional
Delivery Model (EDM) for key work which set out the priority prisoner groups for
whom it was recommended that key work should continue. The priority groups
included prisoners at risk of suicide or self-harm and prisoners who had been
advised to shield because they had been assessed as clinically extremely
vulnerable to COVID-19.
98. Mr Petrou had a key worker session on 19 August 2020, while he was on an ACCT,
but he had no further key work sessions after that. In January 2021, Mr Petrou was
assessed as clinically extremely vulnerable to COVID-19 and he started shielding.
In line with the EDM, he should have been allocated a key worker.
99. We acknowledge the significant pressures faced at Pentonville around the time of
Mr Petrou’s death because of reduced staff numbers and the impact of the COVID-
19 restrictions. However, we consider that Mr Petrou should have had a key worker
from January 2021, while he was shielding. We recommend:
The Governor should ensure that during a restricted regime, key work is
delivered in line with the Exceptional Delivery Model.
Violence reduction
100. A Prisons and Probation Ombudsman (PPO) publication in October 2011, Violence
reduction, bullying and safety, noted the links between bullying and violence and
self-inflicted deaths of prisoners of all ages. In our PPO thematic report into self-
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inflicted deaths in 2013-2014, we found that reports or suspicions that a prisoner is
being threatened or bullied need to be recorded, investigated and responded to
robustly.
101. Pentonville has a violence reduction policy dated 20 February 2020, which sets out
the process for raising and investigating any identified or suspected acts of
aggression, bullying, intimidation, or violence. An intelligence report was submitted
on 8 December 2020, which said that Mr Petrou (and other prisoners) were possibly
being bullied by a prisoner on C Wing for money and their canteen. There is no
record of this information on Mr Petrou’s prison record and no evidence this
information was shared with Safer Custody or if any follow up action was taken to
investigate. There is no evidence that Mr Petrou raised any concerns about being
bullied with staff.
102. We are concerned that more was not done in response to the information submitted
to security. Violence reduction measures (Challenge, Support and Intervention
Plan (CSIP)) should have been considered in response to this intelligence report.
103. Staff at Pentonville hold a weekly Safety Intervention Meeting (SIM) to discuss
managing the risks to prisoners and the prison. It is attended by heads of function,
including security, safer custody and healthcare managers. There is no evidence
that Mr Petrou, despite his vulnerabilities and assessed high risk of suicide and self-
harm around the time of sentencing, was referred or considered by the SIM. This
was a missed opportunity to provide him with additional support.
104. We recommend:
The Governor should ensure that staff:
• investigate suspected or alleged bullying in line with the prison’s
violence reduction policy;
• support victims of bullying by making CSIP referrals; and
• refer cases to the Safety Intervention Meeting where appropriate.
Safer Custody helpline
105. On Saturday 27 February, Mr Petrou’s daughter left a voicemail message on the
Safer Custody hotline saying she was concerned for her father’s safety, but staff did
not listen to this message until after Mr Petrou had died.
106. A senior manager told the investigator that the recorded message on the Safer
Custody hotline advises callers that the line is monitored Monday to Friday 9.00am
to 5.00pm and that if the caller requires an urgent response, or the call is an
emergency, they should call the prison’s Control Room number which is always
staffed. The Control Room did not receive a call.
107. Following Mr Petrou’s death, Pentonville reviewed how it monitors voicemail
messages. The senior manager told the investigator that every Friday, the Safer
Custody Team email the weekend duty managers and operational managers to
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remind them to periodically check the Safer Custody voicemail. Managers are
asked to respond to any immediate risks or send an email to the Safer Custody
Team mailbox to alert them to any non-urgent matters.
108. As Pentonville has already reviewed and changed the process for monitoring Safer
Custody voicemail messages at weekends, we make no recommendations.
Inquest
109. The inquest into Mr Petrou’s death concluded in October 2024 and recorded Mr
Petrou’s death was suicide due to partial suspension.
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