Marcus Hanlin Inquest – Katherine Khorsand

Katherine Khorsand gave her evidence shortly after midday on Day 1 of Marcus’s inquest. She told the court that she works for Dean Healthcare as an agency nurse.

Asked by the coroner how well she knew Marcus she responded “quite well”.

KK: I knew Marcus quite well, close to 2 years [can’t hear] he got on with me, we got on well… I knew him very well really…I was there when he moved in, he seemed to take to people quite naturally, initially he liked relationships with men, but he had a soft spot for me, so we got on quite well.

C: As an agency nurse were you aware of the difficulties Marcus had around drinking and swallowing?

KK: Yes, I’d worked for 2 years for Brandon Trust as a nurse, at one point I had to leave and I came back as agency.

The coroner asked Ms Khorsand about the speech and language therapy assessments she’d mentioned, and what she understood “Marcus’s problems were at the time”.

Ms Khorsand told the court that Marcus did enjoy his food. That he would need to be accompanied in the kitchen or dining area.

“At one point he had moist and mashed, cut up small when he first came to us, as time went on he had a few chest infections, had a cold for example, we pureed food so it was easier for him to swallow, SALT guidance suggested we kept at that. He’d eat very quickly so you’d need to be next to him, to slow the pace down. Ended up giving him teaspoon to eat, so he couldn’t bolt the food down, sometimes two plates as well just to slow him down a bit”.

C: Thank you, now I know you’ve provided a statement via one of my Coroner’s Officers, you spoke to Linda Brown. My understanding was that was in relation to a concern you had around eye catching activities being left out. Could you just explain what that concern was.

KK: Yes, I came in one evening, hadn’t worked at the home for a couple of weeks. Came in, had handover, noticed on the dining room table there was rice, no sand, pink and blue sand. It looked quite eye catching, was in a round dish. I thought I better move that in case Marcus, or anyone else would sit down, because it was on the dining room table, would think was food, so I went into the kitchen and put it onto the refrigerator, out of reach.

C: Did you communicate that concern to anyone?

KK: Yes I said to the member of staff on duty, look at this, think we better move it in case anyone picks it up, they said definitely. I would normally write in the communication book, I didn’t always see the manager because it was an evening shift. In handover the next morning I said need to be more vigilant of activities in case any of the residents think is food.

C: Thank you. On the day in question, the incident on 28 September, were you working that day?

KK: No

C: Your involvement was at the hospital, is that right?

KK: Yes

C: How did you become involved then?

KK: I hadn’t been working at Cheddar for a couple of weeks, randomly called up, was left a message Marcus is in hospital, have you got time to pop in and relieve Laura, the activities coordinator. I assumed he’d fallen or tripped, his cataracts were getting worse, and I was told no he’s eaten some rice. I didn’t really understand that. I thought it was rice you could eat. I went along and met Laura in hospital, about 5 o’clockish, it was a dark night, was raining… not sure how long she’d been there.

C: That’s Laura Bolus?

KK: Yes

C: You met her in the hospital, where did you meet her?

KK: A&E, and I was taken to a room off of [can’t hear], small ward with lots of beds. I heard Marcus before I saw him [can’t hear] walked into the ward, saw him there

C: What did you discuss with Laura about what had happened?

KK: She just said, she was so busy trying to care for him, she had a tissue, was wiping his nose and mouth, calming him down, trying to put a mask on him. We were really more interested in taking care of Marcus at that point, pacify him really, try to get him to use the mask, he did do quite well with the mask, was ok. We didn’t really talk, all I assumed was what I was told before… we didn’t discuss it at that point at all. Was just told he had rice…

C: So who told you rice [can’t hear]?

KK: Laura. Then at that point, doctors called for him to have an x-ray, move to another room, they brought a mobile x-ray, I went off to try get Marcus a wheelchair, thought if he sat down he’d get proper x-ray for him, was on the bed, was moving a lot, he wouldn’t settle, he was very distraught… I just thought that would be easier option for him to sit down, I said I’ll put lead jacket on and I’ll hold him so you can get a decent picture, they said no no, no cant do that, we’ll just do the best we can. I think he sat on the floor. At that point Laura said do you mind if I go now, is getting late, 6 or 7 o’clock. I said yes, I’m here now, I’ll stay with him.

With that the x-rays came out… was all white fuzzy presentation, was nothing you could see, right down at the bottom of the x-ray where the hip bone would be was a round ball, about golf ball size.

She said as she was going, ‘Do you think that’s a conker?’ and I said “Where would he get a conker from?’ She got quite emotional, said I’m not sure, I’m not sure, there might have been some small ones, she put her fingers up [gestures the size with her thumb and finger], small ones, might have been on the table… then she left.

Then they moved Marcus to another ward. I did say to her before she left, they’ve got the x-rays, whatever they find they’re going to find, I was trying to calm her down, said whatever they find they’ll find.

C: OK, when she was saying about the conker and was upset about that, where was she saying, who was in the room when she was talking about the conker?

KK: The chaps doing the x-ray were there, there was doctors and nurses walking around, whether they heard or not… I suppose, I guess [can’t hear]. She was getting quite emotional, so I left it… the physio came and started trying to have a look at him, I just concentrated on the next for him, what was going to happen.

C: OK, did you then mention the conker to anybody?

KK: I didn’t… I was looking after him, he was all over the place. When she said it couldn’t have been, the size she was saying was so small… I thought maybe the ambulance crew would have taken the plate as evidence of what he was eating, wasn’t thinking of that, was thinking of supporting Marcus.

C: OK, can I just go back, you’re saying there was an x-ray, on the x-ray was a round?

KK: It was right down the bottom of the x-ray, nothing at the top, was cloudy, I thought that was the rice, it was still coming out of his nose and mouth, white… I assumed he’d aspirated on the rice, it was everywhere. Seemed to be like a ball right down at the side of this x-ray… I was thinking the hospital staff would see something.

C: OK, was that the only day you were involved with Marcus at the hospital?

KK: I think I stayed 3 nights with him

C: You stayed 3 nights, alright. Is there anything else you want to say about his stay at the hospital?

KK: I think the hospital did what they could with him, initially maybe they didn’t know how to interact with him… we found different ways of doing things.. they took it on board… I thought they were very good with him, physios there, they treated him with respect … experienced staff amongst them could clearly see they knew what they were doing, one physio was quite young.

C: OK. I’ll ask others to ask some questions, may come back to you at the end.

OL: Thank you very much. Good afternoon, I think you heard Anna gave her statement… page 52 paragraph 22, she said Marcus’s previous keyworker… tried very hard to maintain chasing up his health appointments. Was that you?

KK: Yes, that was me

Oliver said that earlier on in the same paragraph Anna had said in her view, the home had been a coherent whole, with a safe family feeling, but that had deteriorated. He asked Katherine if she agrees with that assessment.

KK: Yeh, I do agree. Some of the staff left, they retired or went elsewhere, there was lots of agency and bank coming in. Yeh, the house it wasn’t the same, new staff were learning.

OL: You’ve mentioned Marcus’s eyesight had deteriorated

KK: Yeh, he had cataracts, he had an appointment two weeks after his death [for cataract surgery]. He was walking around, he was tripping over things, he was looking definitely at things close up to make sure was food, and other objects he saw.

OL: Was that something you observed on the shift you did on 12 September, or before that?

KK: When I went into that shift there was no-one in the dining room so I just moved it anyway, I was worried he could clearly have thought it was food.

OL: On his eyesight my understanding was you did shifts less frequently than before, what did that mean?

KK: I was working 3 or 4 shifts a week and then dropped down to 1 every 2 or 3 weeks

OL: In the weeks leading up to Marcus’s death did you notice his eyesight had deteriorated?

KK: Yes I think he was looking a lot closer at objects in front of him

OL: Was that something that caused you to have alarm, when you saw that?

KK: Yes I wasn’t sure, it might have been there days or weeks I don’t know but I thought I’d move that.

OL: We also know Marcus had a diagnosis of Alzheimers

KK: Yes

OL: Were there symptoms something you were aware of?

KK: I didn’t see much change in Marcus.

OL: From your experience looking after him, were there times when he thought non-food items might have been food?

KK: No

OL: From your experience of looking after him, you’ve been there when he’s had meals had you?

KK: Yes

OL: Would he have known what rice was, do you think?

KK: We wouldn’t have rice in the house at all because it was a choking risk. We didn’t have rice at all, so he might not have known. I think this was a hard rice, that hadn’t been cooked.

OL: You say in your statement you emailed in, any concerns I have I write them in the communication book for staff to read when they come on duty next, am I correct in thinking you did write in the communication book on that shift?

KK: I would normally, but I don’t remember. Its usually kept on window sill but I hadn’t been there for a while, my priority was to get residents their support and get them to bed, I did write in there but I can’t remember if I did that day, but I did mention in handover the next day.

OL: Bundle p534 is that your entry that goes over the page?

KK: Yes

OL: Is that your signature, I think it starts with K?

KK: Yes

OL: Is that the communication book you refer to?

KK: Yes, looks like it

OL: You have made an entry there on the 13th?

KK: Yes. That was about the forthcoming apportionment.

OL: Take a moment to read all your entry there.

KK: Yes, that wasn’t anything to do with, that was forthcoming appointment

OL: You say in your statement, when you have a concern you would write in the communication book. Why is it that day you didn’t?

KK: I couldn’t find it, it’s usually kept on the window but it wasn’t there that night, I don’t know if I actually found the communication book that night at all.

OL: This is the communication book?

KK: Yes

OL: This is a photocopy, that’s the communication book?

KK: Yes

OL: My question is if you had concern … why didn’t you record that concern in the communication book?

KK: I couldn’t find it at that time, by the time evening had gone, put people to bed, I said to myself I’ll tell them in the morning. I thought it was there, but if its not I didn’t… because I’m agency I don’t see the manager.

Oliver asked if Ms Khorsand had raised it with the manager. She told the court that she raised it with the nurse following her. She thought it was the weekend, she said that she definitely said “can we not be leaving things around because accidents happen”.

OL: Are you aware of any action taken by management as a follow up?

KK: No, I don’t think I went back for a while.

No further questions from the family. Next it’s over to Rhys Hadden for UHBW. He introduces himself and who he asks questions on behalf of.

RH: You provided your recollection of what happened in the hospital on that day, and your handover with Laura Bolus. You mentioned seeing two x-rays shortly after you arrived, that took place shortly after that happened, was that just with you and Laura present looking at the x-rays?

KK: Me and Laura, and there was some nurses and doctors around.

RH: Can I ask you to turn to the second bundle, pages 167 and 168

KK: I’ve got the x-ray here

RH: Yes, two x-rays here, you said in evidence prior to seeing x-ray had been no discussion with Laura… your evidence was you were focused on trying to comfort Marcus and ensure his needs were being met?

KK: Yes

RH: Two x-ray images here… were those the two x-rays you saw?

KK: I don’t recall that, what I saw was all was cloudy, I couldn’t see that at all

RH: Page 168 you’ll see?

KK: Yes that white cloudy, I saw all the way down the lungs, yes that was it.

RH: This is not a criticism, you’re not a trained radiologist are you.

KK: No

RH: That black object on the left side, was that it?

KK: It could have been, yes

RH: Is that what prompted your conversation with Laura?

KK: Yes, Laura said could that have been a conker?

RH: The expert has said a conker is not radio opaque, it wouldn’t necessarily show up on an x-ray, I’m giving evidence slightly here, we have a witness from the Trust who will say that dark object is the stomach

KK: Yes, I thought it might be an organ

RH: But that triggered the conversation with Laura that could be a conker?

KK: Yes

RH: But that wasn’t discussed further in the time you were there?

KK: No

RH: You said you stayed with Marcus on the first night?

KK: Yes

RH: And you came on his last night?

KK: Yes

RH: How many nights were you with Marcus?

KK: I was there the first night, someone else did the second night agency I think… then I think I did one more night.

RH: Your evidence was you’re someone familiar to Marcus … you helped nursing staff understand Marcus?

KK: Yes, I did

RH: Was that most prominent during the first night?

KK: Yes, no one knew what had happened really, he was very distressed and distraught I guess, lots of staff were coming in to have a look at him and do different things with him, I was trying to relax him

RH: Following that, your evidence was staff provided very good care to him?

KK: I thought so, yes

RH: Thank you, no further questions.

C: Mr Lindsay?

SL: Just one question ma’am if I may. Ms Khorsand, would you turn to bundle 3 and look at page 81. Laura Bolus’s statement, discussed whether Marcus swallowed a conker, said unlikely to happen given Marcus had no teeth and on a pureed diet, is that your recollection of the conversation?

KK: It wasn’t really a discussion, was couple of brief sentences, yeh

SL: Was it your view it was unlikely to have happened to him?

KK: No. It was Laura’s. She said the conker was very small, it wasn’t the big object we were looking at. She said she didn’t know, she didn’t know if he’d eaten any conkers. I said they’ve done the x-rays they’ll find whatever they’ll find.

SL: Thank you ma’am.

No questions from Mr Cousins for Laura Bolus. Then it was over to Mr Brownhill, who represents Brandon Trust.

IB: Thank you. I ask questions on behalf of the Brandon Trust.

KK: Yes

IB: You said before things had changed in staffing at Cheddar Grove,  remember saying that?

KK: Yes I did

IB: You’d gone from full time employed to being agency staff?

KK: That’s right

IB: When did you do that?

KK: I can’t remember the dates, the manager who worked there at the time was coming up for retirement, lots of staff were moving out and changing, I just thought it was the best time to go.

IB: The manager had retired?

KK: Was going to, I think she had to do 6 months before she retired.

IB: Tail end of the pandemic, lots of people were changing jobs?

KK: Yes

IB: You decided you still wanted to work with Brandon Trust

KK: Yes, I had good relationships with the residents and their families, and thought I’d go back, I was working elsewhere as well, it was ad-hoc when needed

IB: There’s a standard system in place if you have concerns about residents?

KK: Yes

IB: You knew what the risks were in the case of each resident?

KK: Yes

IB: Yes. The business at the hospital, to be clear, you weren’t present when paramedics were handing over Marcus were you?

KK: No

IB: You weren’t there when Laura arrived at hospital?

KK: No

IB: In three nights you were there, none of the staff asked you what had happened to Marcus?

KK: No. I got there 4 or 5 hours after he’d got there, no one asked me. I just assumed everyone knew what was in that dish and were dealing with that situation.

IB: So you don’t know what was said to the ambulance crew, or what was said on arrival?

KK: No, no

There were no further questions for Ms Khorsand and she was released before Mr Stevenson returned to the stand for the first time.

[We also heard evidence from the Registered Manager of Cheddar Grove, Keaton Pullen, but my hands are too sore to type more tonight, will report that tomorrow. Thanks to those reading, sharing, supporting and funding my reporting].

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