Daniel Onley · Prevention of Future Deaths report

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Issued 19 Sep 2013•Gloucestershire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Insufficient supervision to safeguard safety and wellbeing
  2. Failure to manage risks associated with medication management
  3. Insufficient arrangements to support taking anti-convulsant medication
    Part of recurring concern: Unreliable support for patients taking prescribed medicationPart of recurring concern: Unsafe medication administration

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.14

  1. The Camphill Village Trust

    Share the Coroner’s concerns with operational managers to support open learning and required practice changes.

  2. The Camphill Village Trust

    Review service staffing adequacy periodically through performance and contract monitoring.

  3. The Camphill Village Trust

    Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.

  4. The Camphill Village Trust

    Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.

  5. The Camphill Village Trust

    Submit the matter to the independent-chaired Safeguarding Board for reflective analysis and organisational-learning comment.

  6. The Camphill Village Trust

    Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.

  7. The Camphill Village Trust

    Establish General Manager and Care and Support Manager posts and appoint additional competent support staff at the Grange.

  8. The Camphill Village Trust

    Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.

  9. The Camphill Village Trust

    Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.

  10. The Camphill Village Trust

    Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.

  11. The Camphill Village Trust

    Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.

  12. The Camphill Village Trust

    Continue constructive collaboration and transparent information-sharing with partner agencies and regulatory authorities on safeguarding concerns.

  13. The Camphill Village Trust

    Remind managers to provide supervision at all times commensurate with each person’s assessed needs.

  14. The Camphill Village Trust

    Respond in a timely and effective manner to concerns about Trust services.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient supervision to safeguard safety and wellbeing

Wider context from the report

“(3) The supervision provided to Daniel during the evening of Thursday 21st June 2012 was not sufficient to safeguard Daniel’s safety and wellbeing. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to manage risks associated with medication management

Wider context from the report

“(2) There had been a failure to manage risks associated with Daniel’s management of his medication. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient arrangements to support taking anti-convulsant medication

Wider context from the report

“(1) That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient. ”

Is this part of a recurring concern?

Yes — Unreliable support for patients taking prescribed medication; Unsafe medication administration.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the Coroner’s concerns with operational managers to support open learning and required practice changes.

Verbatim wording from the response

“6 Organisational Learning”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review service staffing adequacy periodically through performance and contract monitoring.

Verbatim wording from the response

“Future audit of arrangements”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.

Verbatim wording from the response

“Policy revision”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.

Verbatim wording from the response

“Regular training on the management of risks has been incorporated into the Trust’s staff training plan.”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Submit the matter to the independent-chaired Safeguarding Board for reflective analysis and organisational-learning comment.

Verbatim wording from the response

“The Trust also placed this matter before its Safeguarding Board (which is chaired by an independent person) for the Safeguarding Board’s analysis and comment in terms of reflective practice and organisational learning.”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.

Verbatim wording from the response

“Future audit of arrangements”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish General Manager and Care and Support Manager posts and appoint additional competent support staff at the Grange.

Verbatim wording from the response

“Specifically, with regard to arrangements in the Grange, i.e. the service where Daniel lived, the posts of General Manager and Care and Support Manager have been established and additional support staff have been appointed with the necessary competencies, knowledge, qualifications, skills and experience to ensure adequacy of staff cover and the safety of the service at all times.”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.

Verbatim wording from the response

“Audit of existing arrangements”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 1 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.

Verbatim wording from the response

“The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made. For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines. The introduction of such a common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes.”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.

Verbatim wording from the response

“Improvements to the management of risks associated with the administration of medicines in trust services”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.

Verbatim wording from the response

“Future audit of arrangements”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue constructive collaboration and transparent information-sharing with partner agencies and regulatory authorities on safeguarding concerns.

Verbatim wording from the response

“The Trust is committed to respond in a timely and effective manner to any concern brought to its attention about its services. Moreover, the Trust will continue to work constructively and positively with partner agencies and regulatory authorities to ensure the safety and wellbeing of people who use its services. This includes continuing to be open and transparent with statutory bodies on known, or suspected, safeguarding concerns.”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remind managers to provide supervision at all times commensurate with each person’s assessed needs.

Verbatim wording from the response

“The supervision provided to Daniel during the evening of Thursday 21st June 2012 was not sufficient to safeguard Daniel’s safety and wellbeing”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Respond in a timely and effective manner to concerns about Trust services.

Verbatim wording from the response

“5 Complaints, Whistle-Blowing, Incident Reporting”

Source location

2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026