"Neglect" contributed to death of Bristol care home resident
Marcus Hanlin died in hospital after inhaling conkers and uncooked rice at Cheddar Grove care home
Last updated 22nd Apr 2024
A coroner has concluded "neglect" by care home staff contributed to the death of a Bristol man with autism.
Marcus Hanlin (57) died at the Bristol Royal Infirmary (BRI) on 2nd October, 2022, after being taken ill at Cheddar Grove care home where he lived.
Suffering from down syndrome, severe learning difficulties and swallowing issues as well as autism, Marcus was supposed to be supervised at all times when around food, or anything he could reasonably think was food.
Despite that staff at the care home briefly left him alone in front of a bowl of conkers and uncooked rice on 28 September, that had been used as part of a sensory activity for another resident.
He was left alone for long enough to inhale some and he died several days later from pneumonia brought on by the incident.
Conkers were not found in his airway until after his death, as care home staff never mentioned to doctors at the hospital that he may have swallowed any.
Concluding proceedings at Avon Coroners Court this afternoon (22 April) senior Avon coroner Maria Voisin said staff knew he was not supposed to be left alone in such circumstances and so doing so constituted a "gross failure".
Marcus' mum Anna Rose read at statement outside the court afterwards.
She said: "Marcus was a very dearly loved family member and a loving man.
"Tragically, some of those with responsibility for his care failed to protect him and Marcus lost his life."
She added that Marcus lost his life "completely needlessly".
"The conclusion that Marcus' death was contributed to by neglect does justice to what has happened to Marcus," she said.
Staff showed a "Jaw dropping level of incompetence"
In a statement read at the opening of the inquest and again in another following its conclusion, Marcus' mum was very critical of staff at the care home, which is run by the Brandon Trust.
Responding to the coroner's conclusion a spokesperson for the Trust said: "The Brandon Trust acknowledges that a mistake was made on the day that Marcus consumed the contents of the sensory activity.
"The Brandon Trust has apologised, and continues to apologise, to Marcus’ family for this mistake. The Brandon Trust acknowledges the coroner’s conclusion that Marcus’ death was contributed to by neglect.
"Since Marcus’ death, The Brandon 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 all staff, a thorough review and audit of all risk assessments, policies and guidance, and changes to the staffing and management structure at Cheddar Grove."
Continuing to speak after the conclusion of the inquest Anna Rose said: "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."
The coroner ruled that a report into the prevention of future deaths is not necessary.