After Trevor’s tragic death, an investigation was carried out into finding the underlying cause of how Trevor had died while in the care of HMPS Lewes. This investigation started on 22 April 2021, it took a long time to gather all the evidence and documentation.

The investigation concluded at the inquest at Hastings Coroners Court in September 2023.

The family were in court for the whole 6 days. Every day we had to hear of the failings that had taken place while Trevor was in their care. We heard about how incompetent the staff were, and the inadequate level of care that was given which all lead to his sudden death. The jury came to a unanimous decision, that Trevor Monerville’s family had won the case but at a very high price – that he did not need to lose his life if the staff of HMPS Lewes had carried out their duty of care.

In their narrative conclusion they found that:

• “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 coroner listed her concerns and found that ‘In particular, there was no seizure care plan, no seizure diary, and once the ACCT had closed on 10 March 2021, there was no formal mechanism of monitoring Trevor’s condition.’ She also found that ‘Communication between healthcare and prison staff, especially when Trevor was returned to the wing, and between the prison staff and family, briefings by prison managers to officers on the wing about Trevor’s condition, were all inadequate.’

As much as it was a relief to know that the family received the answer they needed, it was not going to bring Trevor back. What happened to Trevor cannot be changed but, action needs to be taken so no one else’s life is taken, and no family member has to lose a loved one in this way.