Daniel Onley

Com philt
a Vilage

Communities with adults, some of whom have special needs, caring about The Kingfisher Offices

the environment, work, economic and social life .
9 Saville Street

and further education.
Malton
North Yorkshire
The Office of Tom Osborne YOU? 7LL
Her Majesty’s Assistant Coroner for Gloucestershire Tel: +44 (0)845 0944638

Gloucestershire Coroners Court
Corinium Avenue

Barnwood

Gloucester

GL4 3DJ

12 November 2013

Dear Sir

Regulation 28 Report to Prevent Future Deaths

| write in reply to your letter dated 19 September 2013 addressed y |

concerning the Inquest into the death of Daniel Onley.

As requested | provide details of action taken by the Camphill Village Trust (the
Trust) to prevent future deaths in response to the matters of concern stated in your
letter.

The action the Trust has taken and proposes to take to prevent future deaths.

1 Concern of the Coroner :

That the arrangements in place to support Daniel to take his anti-convulsant
medication were insufficient.

Improvements to the safe administration of medicines in Trust services

Audit of existing arrangements

Between 15 May 2013 and 8 July 2013 internal audits were carried out in each of the
Trust's nine communities to assess compliance against the requirements of CQC
Essential Standards of Quality and Safety Outcome 9 (Management of Medicines).

Where required, managers have acted upon any actions required to improve the
safe administration of medicines in their service.

Patrons: The Duke of St, Albans, The Lord Hastings Founder: Dr. Karl Kénig
The Camphill Village Trust Limited is a registered Charity 232402 England & Wales and is a non-profit company
limited by guarantee 539694 England & Wales. Registered office: The Kingfisher Offices, 9 Saville Street, Malian, North Yorkshire YO17 7H.

A member of the Association of Camphill Communities

Fax: +44 (0)1653 228228
trustoffice @cvt.org.uk

Policy revision

The Trust has completed an extensive review of arrangements concerning the
handling of medicines and has implemented a policy focused on the safe
administration of medicines in its services. The Trust's Medicines Policy complies
with :

e the requirements of the Care Quality Commission regarding the management
of medicines, and,

e guidance issued by the Royal Pharmaceutical Society on the safe handling of
medicines in social care settings

The key purpose of the policy is to provide managers and staff with a clear
framework to ensure best practice when handling medicines and thereby to protect
people who use the service from risks associated with the unsafe administration of
medicines.

The policy lays out the safe and appropriate arrangements for staff to follow for the
obtaining; recording; handling; safe keeping; administering and disposal of
medicines.

Future audit of arrangements

Under the direction of the Trust’s Operations Director, compliance checks will be
carried out periodically (at least once every six months) to assess the quality of
service delivery against the requirements of the Trust’s Medicines Policy.

2 Concern of the Coroner :

There had been a failure to manage risks associated with Daniel’s management of
his medication

Improvements to the management of risks associated with the administration

of medicines in trust services

The Trust's Medicines Policy lays out the actions managers and staff are required to
follow to ensure any risks associated with medicine taken by a person using the
service are identified, clearly documented and acted on through :

e a written risk assessment (A) to identify any areas of risk the person is
exposed to regarding the administration of any medicine they are taking.
These risk assessments are required to be routinely reviewed every six
months, or sooner if a person’s prescription is changed or if any concerns
come to light about any aspect of the safe management of medicines.
Examples of what could trigger a non-routine re-assessment could include an
observed deterioration in a person’s health or wellbeing; concern that a

person may not be taking their medicine as prescribed; evidence of lost or
otherwise unaccounted for medicines

* awritten mental capacity assessment (B) to determine the person’s ability
to safely manage any aspect of handling their medicines. These capacity
assessments are required to be reviewed every six months, or sooner if a
person’s prescription is changed or if any concerns come to light about any
aspect of the safe management of medicines, and,

On completion of (A) and (B), a written description of the level of assistance a
person requires for the safe administration of their medicine is made and entered
into the person's care record.

The Trust’s Medicines Policy makes it clear to staff that all documentation relating to
the administration of a person’s medicines must be current, clear, complete and
correct.

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

Future audit of arrangements

Under the direction of the Trust's Operations Director, compliance checks will be
carried out periodically (at least once every six months) to review the quality of risk
assessment documentation, mental capacity assessment documentation and
documented support provided to people using the service who take medicine.

3 Concern of the Coroner :

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

On 24 September 2013 managers were reminded in writing of the need to ensure
that adequate and appropriate supervision commensurate with each person’s
assessed need is provided at all times in order to ensure the safety and wellbeing of
all people using the service.

In the event of any unexpected shortfall in staff numbers or availability, managers
are expected to ensure the adequacy and safety of the service through the provision
of relief or agency staff.

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.

Arrangements to ensure appropriate assistance is available to respond to any
untoward or emergency situation occurring between 10.00 pm and 7.00 am is
provided in line with assessed need and any clearly documented funding authority
expectations.

Future audit of arrangements

The Trust’s Operations Director will ensure that the adequacy of service staffing
arrangements is reviewed periodically under performance and contract monitoring
arrangements.

Other Matters

4 Disciplinary action

Disciplinary action was taken against three individuals regarding their care and
support of Daniel.

5 Complaints, Whistle-Blowing, Incident Reporting

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.

6 Organisational Learning

The Camphill Village Trust Board of Trustees is committed to ensuring lessons are
learned from this tragic incident and supports the Trust's senior managers in taking
necessary steps to avoid a similar incident occurring in the future.

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.

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.

At its meeting on 5 November 2013 the Safeguarding Board expressed the view that
it considers the concerns identified by the Coroner are being addressed and has

asked that regular audits are carried out to ensure continued safe practice and for
the findings of these audits to be reported back to the Safeguarding Board.

| trust this letter provides reassurance that the Trust has taken appropriate action to
prevent future deaths but please do not hesitate to contact me if further information
or clarification is required.

Yours faithfully

Huw John
Chief Executive

The Camphill Village Trust