Marcus Hanlin Inquest – Family statement

Marcus was a very dearly loved family member and loving man. Ineffective management at Brandon Trust meant that care was not provided as it should have been, and as a result, he lost his life. His death was completely avoidable. While we acknowledge the necessary changes by the Brandon Trust following Marcus’ death, we only […]

Marcus Hanlin Inquest – Brandon Trust Statement

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 the mistake. The Brandon Trust acknowledges the coroner’s conclusion that Marcus’s death was contributed to by neglect. Since Marcus’s death, the […]

Marcus Hanlin Inquest – Coroner’s Summing Up

The Senior Coroner for Avon, Maria Voisin, returned to court this afternoon, on Day 6 of Marcus Hanlin’s inquest, to give her summing up and conclusion. She said that she was aware that people would be trying to take a note and that she would try and go slowly [even with this I still could […]

Marcus Hanlin Inquest – Conclusion

Part 3 The deceased was Marcus Jon Hanlin. He died on 2 October 2022 at Bristol Royal Infirmary. Marcus was cared for in a nursing home. He suffered with Down Syndrome and had dysphagia. There was a care plan and guidance in place for staff to follow to keep him safe. On 28 September 2022 […]

Fern Foster Inquest – Family Statement

Three of Fern’s family members, her mother Dominique Jowett (report on her evidence here), father Kieran Foster (report on his evidence here) and sister Rowan Foster (report on her evidence here), gave evidence to the coroner during Fern’s inquest. They also provided a pen portrait of who Fern was. At the end of Fern’s inquest […]

Fern Foster Inquest – Coroner’s Summing Up

I have already reported the coroner’s conclusion in Fern’s inquest here, but for completeness wanted to also write up his summing up (as far as I am able, it was fast). Senior Coroner Crispin Butler started by thanking those who have assisted the court. He said that he would present his brief summary, which led […]

Fern Foster Inquest – Melissa Hinton, Oxford Health PFD Evidence

The final witness to give evidence at Fern’s inquest was Melissa Hinton. She gave evidence after lunch on Day 11. She gave an affirmation. C: Can I thank you for attending the inquest today, and you and your colleagues, for proactively considering matters as they’re unfolding and providing additional evidence to assist me in learning […]

Fern Foster Inquest – Dr Tina Malhotra, Oxford Health PFD Evidence

The first witness on Day 11 of Fern Foster’s inquest was Dr Tina Malhotra, who is a Consultant Psychiatrist and Clinical Director at Oxford Health NHS Foundation Trust. She gave an affirmation and the coroner welcomed her, saying that he was hearing from her in relation to learning, actions and implementation following Fern’s sad death. […]

Fern Foster Inquest – Narrative Conclusion

Fern Foster’s death was verified at around 15:20 on 8 July 2020 at her current accommodation. Fern had received news that day concerning the intended adoption of her child, in circumstances where professional support, including independent advocacy was not physically present at the time, to try to assist Fern with processing the information to safeguard […]