Source: Courts and Tribunal Judiciary
published: 19 January 2024
Rachel Redman, Assistant Coroner for the coroner area of East Sussex published 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.
On 22 April 2021 she commenced an investigation into the death of Trevor Alan Monerville, aged 33. The investigation concluded at the end of the inquest on 25 September 2023.
The conclusion of the inquest was a narrative verdict finding that Trevor Alan Monerville died as a result of natural causes, namely SUDEP having suffered from epilepsy and non epileptic attack disorder. He was detained at HMP Lewes initially on the healthcare wing, and then on M wing in a single cell. Monitoring ceased once the ACCT was closed on 10 March 2021.
On 18 April 2021 in the morning, Trevor was found unresponsive in his cell and death was confirmed soon after. The communications between all organisations within the prison and between the prison and outside agencies, the monitoring systems, the sharing of medical information and engagement with Trevor’s family were found to be inadequate and there was insufficient and inadequate management of Trevor’s care.
Trevor Monerville had been detained at HMP Lewes since 30 November 2020. He was moved to M wing on 16 January 2021. He was placed in a single cell and appeared settled and was part of the daily cleaning crew.
He was last seen by the night staff at around 0500hrs on 18 April 2021 during routine checks.
At 0950hrs he was found unresponsive face down in his cell floor. Prison staff rolled him onto his back and saw blood around his nose. CPR was started and am ambulance called. The ambulance crew continued CPR in spite of obvious signs of rigor mortis in his lower limbs for approximately 1 hour. A brief search of the cell revealed a significant quantity of medication in tablet form some of which was no longer coated and stuck together indicating it had been removed from the mouth.
The cause of death found at post mortem examination was 1a Sudden Unexpected Death in Epilepsy.
