Gross neglect contributes to death of man with Down's Syndrome

Marcus Hanlin

An inquest has concluded gross neglect contributed to the death of a care home resident with Down's Syndrome.

Marcus Hanlin, 57, died after choking on a conker that was part of a sensory activity for another resident.

Mr Hanlin had been left alone in a room, despite being on a support plan that required him to be supervised at all times when around food due to a choking risk and swallowing issues.

The Brandon Trust, which runs the Bristol nursing home has apologised.

A spokesperson said the trust acknowledged the coroner's decision and said it had taken "robust action" to "avoid anything like this happening again".

Mr Hanlin's mother, Anna Rose, said her son was "in his own right a remarkable man".

"He had all these conditions to cope with yet something in him made a massive impact on people who got to know him."

Mr Hanlin was on a regime at Cheddar Grove Nursing Home that included him only eating pureed meals and being kept away from food preparation areas.

However, on 28 September 2022, he was left alone in the dining room of the specialist home with a bowl of coloured rice in which conkers were hidden that had been prepared as an activity for other residents. He swallowed some rice and two conkers, leading to him choking.

Eve Salthouse, the compliance coordinator for The Brandon Trust, said on the day of the incident Laura Bolus, a support worker and activity coordinator, had organised the sensory activity.

Ms Bolus said at the time she did not see this as "unadaptive" food and did not think Marcus would eat it, but she was aware Marcus might pick up food which was not suitable for him.

Anna Rose said her son "didn't have a bad bone in his body"

The coroner, Maria Voisin, said: "At some point Laura Bolus left the dining room to check on another resident. When she returned she noticed the conker dish moved, rice and conkers on the floor. She described Marcus as spitting bits of rice out".

The inquest in Flax Bourton, near Bristol, heard a paramedic who was called to the home was not told at first that conkers had been secreted in the rice.

However, when she learned this, she discounted them as the possible cause of choking and did not pass the information on to hospital staff.

The presence of one conker in his oesophagus and another in his stomach was found only after his death.

The coroner concluded: "Marcus was clearly in a dependent position.

"There was a clear failure to provide the care Marcus required. His needs clearly set out in a 'Plan for Life' (care plan) meant staff were aware of this plan for him and to keep him safe."

She added: "The support worker should have realised the risk of leaving unadaptive food where he can get it. I consider it was a gross failure."

The charity Inquest, which is supporting Mr Hanlin's family, said before the inquest that his death was one of at least 18 since 2015 involving vulnerable people with learning disabilities who died by choking or after a swallowing incident in a care setting.

Marcus Hanlin was left unsupervised with a bowl of brightly-dyed rice, in which conkers were hidden

Jodie Anderson, Mr Hanlin's case worker, said: "There were 10 reports issued by coroners, with recommendations in each of them to prevent future deaths from occurring. And we're still here seeing deaths occurring so clearly.

"There is a cultural difference and lack of learning from care providers to really think about the issues that coroners are raising; staffing and resourcing, a lack of vigilance management.

"We really need a sector-wide review within health and social care to acknowledge these recommendations and implement the findings."

The Brandon Trust said it "continues to apologise to Marcus' family for this mistake".

'Dangerous' systems

The spokesperson said since his death the trust "has taken robust action to identify all lessons that can be learned to avoid anything like this happening again".

"This has included enhanced training for staff, a thorough review and audit of all risk assessments, policies and guidance and changes to the staffing and management structure at Cheddar Grove."

Ms Rose added: "I am relieved for the remaining residents of Cheddar Grove that they are now so much better protected, but we regret that our lovely Marcus suffered and died before The Brandon Trust realised how dangerous their systems were."