Allison Munroe KC of the Garden Court Inquests and Inquiries Team, instructed by Paul Ham and Constance Collard of Birnberg Peirce Solicitors, represented the family of Trevor Monerville at his inquest at Hastings Coroner’s Court between 18 - 25 September 2023.
Trevor Monerville was a 33 year old man from Hackney. He was naturally gifted and interested in all things mechanical and computing, and had other interests including art, poetry, cookery and baking. Trevor was diagnosed with epilepsy in 2016 and had experienced frequent seizures since that time. He was taking daily medication. Trevor died from Sudden Death in Epilepsy (SUDEP) whilst at HMP Lewes, having been found unresponsive in his single cell on the morning of 18 April 2021.
An inquest concluded that there was insufficient and unacceptable management of Trevor’s care, inadequate for his needs. This is in relation to both HMP Lewes and the privately owned prison healthcare provider, Practice Plus Group (PPG).
In their detailed narrative, the jury unanimously concluded:
- “The communications between all the organisations involved, the monitoring systems, the sharing of medical documentation and the engagement with Trevor’s family were inadequate for Trevor’s individual needs.”
- Even with consideration of staff shortages and the pandemic, “there were and still are not systems in place to have oversight of vulnerable people in Trevor’s position.”
- From their observations of some witnesses, “there is a lack of empathy for the people under their care and tenuous accountability for taking ownership.”
The jury also found there was “no system in place to monitor and document Trevor’s seizures, in the absence of a care plan and a seizure diary”. This contributed to staff not being briefed on Trevor’s vulnerabilities.
This absence, alongside the lack of systemic observations after the ACCT closed, “contributed to the insufficient and unacceptable management of Trevor’s care.” As did the ongoing issues in prisons and healthcare with various IT systems not being integrated.
The full press release from INQUEST can be found here.
See press coverage: The Independent
