Trevor Monerville

Director General Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

 7 March 2024 

Rachel Redman  
Assistant Coroner for East Sussex 
Unit 56 Innovation Centre 
Highfield Drive 
St Leonards on Sea 
TN38 9UH 

Dear Ms Redman 

Thank you for your Regulation 28 report of 4 January 2024 addressed to the Minister of 
State for Prisons, Parole and Probation and Practice Plus Group following the inquest into 
the death of Trevor Monerville at HMP Lewes on 18 April 2021. I am responding on behalf 
of HMPPS as Director General of Operations. 

I know that you will share a copy of this response with the family of Mr Monerville, and I 
would like to express my condolences for their loss. Every death in custody is a tragedy and 
the safety of those in our care is my absolute priority. 

Following evidence heard at the inquest you have raised concerns around care plans for 
complex healthcare issues, communication between healthcare and prison staff and 
epilepsy training for prison staff.  

As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical 
matter, falls within the responsibility the healthcare provider at HMP Lewes, Practice Plus 
Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a 
standard wing and, where a health condition such as epilepsy is identified, whether the 
severity of this means they should be located on the inpatient wing. HMPPS will facilitate a 
move to the inpatient unit where this is required. 

If healthcare advice is that the prisoner can be managed on normal location, prison staff will 
facilitate and monitoring by healthcare that they consider necessary. 

It was accepted during the inquest that the ACCT process was not the appropriate 
mechanism to monitor Trevor’s condition. Training has been provided to all relevant staff 
regarding the correct implementation of the ACCT procedures. 

There are Information Sharing protocols in place, as directed by national policy, which 
underpin the exchange of information between healthcare and prison staff. There are 
several regular meetings involving healthcare and prison staff where individual issues are 
raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary 
Complex Case Clinic, both of which are held weekly. 

 
 
 
 
 
 
  
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Safety Intervention Meeting (SIM), chaired by the Head of Safety, and has healthcare 
representation, discusses complex safety cases. This is an appropriate mechanism 
whereby the prison and healthcare staff can report concerns to security about individuals 
and provides reassurance that prisoners are managed effectively. 

The Multi-Disciplinary Complex Case Clinic (MPCCC) is chaired by healthcare. Prison staff 
are invited to attend to raise and discuss complex patients/prisoners. Additionally, any 
patients pending transfer back to the main wing with ongoing needs will be discussed. 

In relation to sharing intelligence, prison and healthcare staff are encouraged to report 
intelligence, including non-compliance with medication, through the Mercury intelligence 
system. All intelligence is triaged daily with actions listed.  

HMPPS recognises that, information sharing is vital to effective health management of 
people in prison and is working closely with NHSE to increase staff confidence and support 
effective information sharing by offering clarity about the general and routine sharing of 
health information and where risk/safeguarding concerns have been raised. 

HMPPS undertake First Aid needs assessments to ensure that sufficient emergency aid 
response is available on each site. First Aid at Work and Emergency First Aid training 
courses are delivered to identified prison staff, which includes emergency response to both 
minor and major seizures.  

In terms of dealing with long term health conditions, PPG are responsible for the 
management and supervision of healthcare issues and prison staff will facilitate their 
instructions.  

Thank you again for bringing your concerns to my attention.  I trust that this response 
provides assurance that action is being taken to address the matters that you have raised.  

Yours sincerely 

Director General of Operations

Practice Plus Group 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

H.M. Assistant Coroner Mrs H.R. Redman 
Coroner’s Office (East Sussex) 
Unit 56 
Innovation Centre 
Highfield Drive 
St Leonards on Sea 
East Sussex 
TN38 9UH 

1 March 2024 

Dear Madam, 

Regulation 28: Prevention of Future Deaths Report – Trevor Alan Monerville 

I write in response to your Regulation 28 Prevention of Future Deaths Report issued to Practice 

Plus Group on 16 January 2024 following the inquest touching upon the death of Mr Trevor Alan 

Monerville at HMP Lewes. Practice Plus Group would like to express its sincere condolences to 

Mr Monerville’s family and friends. 

This response addresses the matters of concern in so far as they relate to Practice Plus Group 

Health & Rehabilitation Limited (“Practice Plus Group”), the lead provider of healthcare services 

at HMP Lewes since 1 April 2020. 

Whilst Practice Plus Group understands the reasons why you were unable to hear oral evidence 

on  these  matters  it  is  unfortunate.  Practice  Plus  Group  were  consistently  able  to  provide  a 

witness  to  give  oral  evidence  and  it  is  considered  that  the  witness  could  have  provided  any 

reassurance  needed  beyond  what  was  contained  within  the  submissions  and  witness 

statements supplied for your consideration. 

Matter of Concern: Consideration should be given to the review of the treatment, monitoring 

and management of patients with a history of epilepsy or seizures by both the prison staff and 

healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the 

Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ACCT had closed on 10 March 2021, there was no formal mechanism of monitoring Trevor’s 

condition. Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy 

is  designed  to  protect  other  prisoners,  but  not  those  who  suffer  from  medical  conditions  as 

Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a 

care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized 

or tailored to the prisoner’s clinical requirements. 

Response: Oversight of patients with long term conditions is currently being carried out by the 

long  term  conditions  nurse  and  primary  care  nurses,  supported  by  the  regional  primary  care 

lead and inclusive of prescribers where applicable. In order to ensure that patients with epilepsy 

are  monitored  and  supported  through  a  patient-centred  approach,  the  long  term  conditions 

nurse has been completing reviews and agreeing a personal care plan with the patient that is 

specific to their individual needs. This is aligned with the wider work that has taken place on 

long term conditions management pathways. 

Practice  Plus  Group  made  it  an  organisational  priority  for  2023  to  ensure  that  the  use  of 

personalised  care  plans  is  embedded  throughout  sites  at  which  Practice  Plus  Group  is  the 

healthcare provider. Using the limited capacity in which Practice Plus Group can make changes 

to  SystmOne,  the  electronic  medical  records  system,  a  care  plan  hub  has  been  created  to 

support clinical staff in accessing appropriate templates. This includes a specific care plan to 

support management of epilepsy and a direct link to the epilepsy care plan has been added 

within the review template for epilepsy annual reviews. Staff received training on the use of the 

care planning hub on SystmOne via workshops, regular updates and in June 2023 staff received 

a care plan guide. 

Care  planning  workshops  for  the  healthcare  teams  at  HMP  Lewes  were  facilitated  by  the 

national and regional primary care leads. The SystmOne recall functionality is being utilised to 

ensure  a  systematic  approach  is  adopted for  long  term  condition  reviews  and  that these  are 

monitored  and  staff  allocated  to  book  patients  into  clinics  when  required.  Healthcare  staff 

working  at  HMP  Lewes  have  also  been  provided  with  access  to  a  training  module  ‘Epilepsy 

training for primary care nurses’. This training is there to provide support on identifying different 

types of seizures, treatment review etc. 

Page 2 of 5 

 
 
  
 
 
 
 
 Practice Plus Group amended the process for reporting on care plans approximately 18 months 

ago and have seen positive progress in the quantitative data. Over the last 3-4 months a process 

to review a small sample of these plans to support quality improvement and align with national 

guidelines has been started. As HMP Lewes is a remand site, the completion rate will always 

be  variable  whilst  new  patients  await  their  initial  long  term  condition  review.  On  review  for 

December 2023, 83% of patients with epilepsy at HMP Lewes now have a documented care 

plan. The team are striving to achieve 100%, however the data taken at the end of the month is 

reflective  of  the  prison’s  population  at  that  point  in  time  and  new  arrivals  in  the  last  few 

days/week  who have  not  yet  received  a  long term  conditions  review  would  affect this  figure. 

Similarly, leavers for who this work had been completed, would not be reflected in the data.  

The  most recent  inspection  report from  HMIP/CQC  dated  23  February 2023  states  “Patients 

with long-term conditions had timely reviews, and a new care plan hub made sure clinicians and 

patients  jointly  managed  care,  which  was  safe  and  well-coordinated”.  We  will  continue  to 

regularly audit and monitor the long term conditions care plans of patients at HMP Lewes to 

ensure progress is maintained.  

Matter  of  Concern:  Communication  between  healthcare  and  prison  staff  especially  when 

Trevor  was  returned  to  the  wing,  between  the  prison  staff  and  family,  briefing  by  prison 

managers to officers on the wing about Trevor’s condition were all inadequate. 

Evidence was heard about the lack of integration of various IT systems which contributed to 

poor  communication.  In  spite  of  the  evidence  from  PPG  regarding  the  sensitivity  of  medical 

records which should not be disclosed to the prison staff, I remain concerned that there was no 

effective monitoring and management of Trevor on the wing once the ACCT was closed. There 

was  no  mechanism  in  place  for  prison  and  healthcare  staff  to  report  their  concerns  about 

Trevor’s non compliance with taking his medication to Security, thus preventing the cell from 

being searched for retained medication. 

Response:  Since  Mr  Monerville’s  death  there  have  been  significant  improvements  in 

communication between healthcare and prison staff, including between the leadership teams. 

There  are  frequent  meetings  and  a  close  working  relationship  is  in  place.  There  has  been  a 

considerable  effort from the Governor to  ensure that  healthcare  is made a  priority  within  the 

prison. 

Page 3 of 5 

 
 
 
 
 
 
 Practice Plus Groups operates an integrated healthcare model. Any patients pending transfer 

back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex 

Case  Clinic  (MPCCC)  prior  to  transfer.  This  allows  oversight  of  all  departments  within  the 

integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, 

attended by all clinical leads, and any relevant staff involved in patient care. For individual cases 

prison  partners  may  be  invited  to  attend  and  a  care  plan  created  with  a  named  coordinator 

allocated. Practice Plus Group has now implemented a further point of escalation to Regional 

MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, 

on occasion, representatives from NHS England. 

Pharmacy  technicians  manage  medication  compliance.  They  have  now  been  given  wings  to 

lead on so that they have  full oversight of patients on their own wing. SystmOne assists with 

supporting the identity of patients who have missed doses. In addition, the IR process is in place 

if it is believed or suspected that a patient might be stockpiling. An IR is an intelligence report 

that will be received confidentially by the security department. 

As to lack of integration of various systems, this is not an issue that Practice Plus Group can 

resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned 

to use SystmOne. As with patients in the community, medical records are highly sensitive and 

personal  to  the  individual.  They  are  not  shared  with  prison  staff  for  reasons  of  medical 

confidentiality. 

Matter of Concern: There was a lack of training of prison staff in dealing with long term health 

conditions such as epilepsy on the wings. I understand there is a deficit in national policy within 

the prison service to manage and support prisoners with epilepsy and seizures. 

Response:  This  concern  is  for  His  Majesty’s  Prison  and  Probation  Service  to  address. 

However,  as  always  Practice  Plus  Group  are  committed  to  working  collaboratively  with  our  

prison colleagues to support the safety and wellbeing of our patients and would fully support 

any prison led epilepsy awareness campaign for officers and wing staff.  

Page 4 of 5 

 
 
 
 
 
 
 
 
 I hope that the above response provides assurance that Practice Plus Group are committed to 

providing a high-quality healthcare service at HMP Lewes and trust this response addresses 

the concerns you had. 

I would like to end this response by taking the opportunity of inviting you to visit the healthcare 

team at HMP Lewes should you wish to discuss and review first-hand the services that Practice 

Plus Group provide, as set out in this letter. 

Yours sincerely, 

National Medical Director, Health in Justice Practice Plus Group 

Page 5 of 5