Avon Coroner’s Court is situated next door to the old long stay institution in Bristol, Farleigh Hospital (now a local enterprise park, belying its history as one of the hospitals where an abuse scandal in the 70s led to the ultimate move to close long stay institutions).

Court 1 has cream walls and a public gallery with 10 rows of plush red chairs. Witnesses for the day were sat in the jury box to the left of the court, and as usual IPs and counsel were at the front. It was a stifling warm room as the sun shone through the skylight above the public gallery.

Senior Coroner for Avon, Maria Voisin took her place on a raised bench at the front of the court at 10:10.

There are 5 sets of interested persons. Marcus’s family are represented by Dr Oliver Lewis of Doughty Street Chambers, instructed by Susie Labinjoh and Sion Morgan of Hodge, Jones and Allen. University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) are represented by Rhys Hadden of Serjeants’ Inn, Marcus spent 5 days in Bristol Royal Infirmary before his death. Brandon Trust, who provided care and support to Marcus since the mid 90s, are represented by Ian Brownhill of 39 Essex Chambers. Laura Bolus, the staff member conducting the art activity that led to Marcus’s admission to hospital, is represented by Andrew Cousins of DAC Beachcroft. The final IP, are South West Ambulance Trust, who are represented by Simon Lindsay, a partner at Bevan Brittan.

The coroner told the court, which was busy with a number of people in the public gallery and a number of press representatives, that her colleague Dr Harrowing had opened the inquest on 10 November 2022. Identification evidence had been collected, and the inquest was adjourned pending further inquiries. She said there had been a couple of pre inquest review hearings.

She then ran through her plan for the next 8 days, outlining witnesses that would be called on each day.

Identification statement

The first witness to give evidence was the coroner’s officer who read a statement from her colleague, onto the record. This was an identification statement that identified who Marcus was, that he had been identified in life by his mother, when and where he was born and when and where he died. The report said that Marcus had a history of Down Syndrome and learning disability, and he had become unwell during a craft therapy event. He was admitted to hospital, his condition deteriorated, and he sadly later died.

Dr Helen Mutch, GP

The second witness was a report from Marcus’s GP, Dr Helen Mutch, also read onto the record by the coroner’s officer. She told the court that she was a GP Partner and had been Marcus’s usual GP since he’d moved to Cheddar Grove. She said that she conducted weekly virtual ward rounds and saw Marcus face to face at the nursing home when needed.

In her report she outlined Marcus’s interactions with the GP surgery since his move to Cheddar Grove in February 2021. She said that the last contact was a staff nurse at the home calling the GP surgery on 28 September reporting that Marcus had eaten uncooked rice and was coughing. When she returned the call she was told that staff had called a 999 emergency ambulance and Marcus had been admitted to hospital. She was subsequently informed that Marcus died in hospital.

Dr Mutch’s report outlined Marcus’s medical history. She told the court that he was on a Level 4 dysphagia diet of pureed food and thickened drinks and that he had recently had an evaluation of his swallow. The report of that had been passed to Sirona Speech and Language Therapy Team for further action, which was usual as the speech and language team have the expertise in that area.

She told the court about gastroenterology investigations that had been conducted, and found to be normal. Marcus had been diagnosed with Alzheimer’s following a scan in 2020 and had a review with the dementia team in September 2022, where he was considered stable and no changes were made.

She also told the court that Marcus had epilepsy and his last recorded seizure was on 17 February 2022, and following that his medication had been increased and there were no further reported seizures.

[We also heard evidence from four other witnesses today: Marcus’s mother, a representative from Bristol City Council, an agency nurse who used to be Marcus’s key worker at Cheddar Grove Katherine Khorsand and the Registered Manager of Cheddar Grove at the time of Marcus’s death Keaton Pullen. I’ll report those as soon as I can].