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Daniel Onley

19 Sept 2013 · Coroner Tom Osborne · Gloucestershire
Check this reportOriginal

The coroner's concerns

  1. 1. insufficient support for medication administration

    “the arrangements in place to support [the deceased] to take his anti-convulsant medication were insufficient”

  2. 2. unmanaged medication risks

    “failure to manage risks associated with [the deceased]'s management of his medication”

  3. 3. insufficient supervision

    “The supervision provided to [the deceased] during the evening of Thursday 21° June 2012 was not sufficient to safeguard [the deceased]'s safety and wellbeing”

Responses

2013-0208-Response-by-The-Camphill-Village-Trust.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error