Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0592, written 25 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2024 |
|---|---|
| Reference | 2024-0592 |
| Deceased | George Kyriacos Petrou |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Mental Health related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Prevention of Future Deaths Report George Kyriacos Petrou (date of death: 1 March 2021) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer Barnet, Enfield and Haringey Mental Health NHS Trust Block 2B St Ann’s Hospital St Ann’s Road London N15 3TH 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 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 4 CIRCUMSTANCES OF 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. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. 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. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of the report, namely 6 December 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and the following: • • Hudgell Solicitors ( behalf of Mr Petrou’s family – Mr Petrou’s daughter ) – solicitors acting on • Practice Plus Group – primary care provider at HMP Pentonville • Ministry of Justice / HMP Pentonville • Care Quality Commission • Prison and Probation Service Ombudsman I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Ian Potter HM Assistant Coroner, Inner North London 25 October 2024
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Headquarters 4th Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 0PE Email: 29th November 2024 Private and Confidential Mr Ian Potter HM Assistant Coroner Inner North London 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 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. Yours sincerely Chief Medical Officer Better Mental Health. Better Lives. Better Communities. Chair: Chief Executive:
See every Prevention of Future Deaths report matching Mental Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.