Trevor Monerville

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

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.

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.

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.

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.

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.