George Kyriacos Petrou

I am Ian Potter, assistant coroner, for the coroner area of Inner North London.

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

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.

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: 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.

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.