11 April 2024

Before HM Senior Coroner Maria Voisin
Avon Coroner’s Court, Old Weston Road, Flax Bourton, Bristol, BS48 1UL
Listed 15 April 2024
Scheduled for 8 days

Marcus Hanlin, a 57-year-old man with Down’s syndrome, severe learning disabilities and autism, died at the Bristol Royal Infirmary (‘BRI’) on 2 October 2022.  

Marcus was non-verbal and had complex health and support needs. He lived in care facilities for the majority of his life, under a Deprivation of Liberty Safeguards (‘DoLS’) order. At the time of Marcus’s death, he was a resident at Cheddar Grove Nursing Home, a specialist nursing home for people with learning disabilities. 

Marcus had particular needs around eating and drinking, which were frequently assessed by the Speech and Language Therapy (‘SaLT’) services. He was subject to an eating and drinking support plan and required supervision at all times when around food due to swallowing issues and an identified risk of choking.

On 28 September 2022, Marcus was left unsupervised with a bowl of dyed rice, in which conkers were hidden, at Cheddar Grove Nursing Home. The dish was part of a sensory activity for another resident at the home. Whilst unsupervised, Marcus swallowed two conkers and some dyed rice. He became unwell and was hospitalised at BRI. 

Marcus’s condition deteriorated and he died four days later. The cause of death was aspiration pneumonia, Down’s syndrome, and pharyngeal and oesophageal obstruction due to ingested conker and aspiration of rice into the lungs. The presence of conkers was only discovered after Marcus’s death.

The inquest will examine the circumstances leading up to Marcus’s death and investigate a number of issues, including:

• The training of staff; SaLT services; staffing; and risk assessments;
• The events on 28 September 2022;
• The management at BRI; and,
• What caused Marcus’s death.

Marcus is one of at least 18 deaths of vulnerable people with learning disabilities and/or autism who died by choking or following a swallowing incident in a care setting since 2015, 10 of which have resulted in a Prevention of Future Death (‘PFD’) report. 

Marcus is described by his family as a real character, mischievous, curious and interested in and affectionate towards others. He loved swimming and specialised cycling and cooking, as well as sitting cross legged in the garden, watching the wind blow through held up grasses or flowers. Marcus was a beloved son and brother whose loss is immeasurable.

Marcus’s family said “As a family we are still in shock at the loss of Marcus. The nature of how this came about, the pain and fear Marcus suffered and the loss of his life in this manner are beyond bearing. Marcus deserves for us to do all we can to ensure the truths of what happened are reached and we hope others can be saved the same suffering and resultant family heartache.”

ENDS

NOTES TO EDITORS

For further information, please contact Leila Hagmann on [email protected]. 

The family is represented by INQUEST Lawyers Group members Susie Labinjoh and Sion Morgan of Hodge Jones and Allen Solicitors and Dr Oliver Lewis of Doughty Street Chambers. They are supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested persons represented are the Brandon Trust/Cheddar Grove Nursing Home, the staff member with Marcus just before the incident, the South Western Ambulance Service NHS Foundation Trust, and the BRI.

Other relevant information:

Marcus is one of at least 18 deaths of vulnerable people with learning disabilities and/or autism who died by choking or following a swallowing incident in a care setting since 2015, 10 of which have resulted in a Prevention of Future Deaths (‘PFD’) report.

In March 2024, INQUEST’s Deborah Coles gave evidence to the Justice Select Committee on the call for a National Oversight Mechanism, citing these deaths of 18 vulnerable as part of a pattern of repeated failings.

Learn more about the No More Deaths campaign