The coroner had earlier checked that Anna wished to read her statement to the court herself. She gave an affirmation and told the court that she was Marcus’s mother, and a retired teacher, lecturer and psychotherapist.

She said that Marcus was a “beloved son” and a “beloved brother”.

“He meant something very special to his wider family and to those who knew him or cared for him”.

She described Marcus as a “real character” who formed “strong and often lasting bonds with those who cared for him”. She told the court that at Marcus’s funeral service there had been moving contributions from his carers and friends, some going back 25 years or more. She said that although Marcus never acquired verbal language he could communicate with those who got to know him.

“Many carers deeply enjoyed and valued his company, and testified to how much he had taught them”

She told the court that Marcus was “at the core of his families life” and that he would remain so in memory, describing his loss as “immeasurable”.

Anna went on to tell the court about Marcus’s life, his diagnoses, and his move into residential care, and the “battles” that they faced across his lifespan. She said he had been in a children’s hospital, then a respite care home, an adult hospital (Farleigh) and he eventually moved into the community to live in 1989.

She said that Marcus having a new home “an ordinary house in an ordinary street was the most wonderful thing to happen”.

She described how Marcus’s house was taken over by Brandon Trust shortly after they formed in 1994. She told the court that they had expanded hugely since then and were now caring for over 1,500 people with learning disabilities.

She told the court that all through his life herself, and Marcus’s older sister, were closely involved with him and his care. They visited regularly and frequently throughout his life.

Anna said that once Marcus moved to Cranwell Grove, the ordinary house, he began to flourish. He shared that home with three other men from Farleigh Hospital for almost thirty years. She said that he also benefitted from day care.

She said his flourishing was a “joy to witness”. She said with time his character became more evident and his qualities of mischievousness, affection, kindness and his humour became apparent. She said that visits to Marcus “became a pleasure” with reducing worries about his welfare.

Anna told the court that improvements in his circumstances began to be affected by cuts to services.

“Marcus had built some inner resilience from these good years, but suffered badly from disruptions to his care”

She told the court that those who were responsible for his care failed to learn and that these battles had to be fought periodically.

She described what Marcus liked and said that he benefitted from carers who were good observers and got to know him. He liked stability and a balance between active times and being involved, with quieter times of withdrawal. She said that Marcus needed to be among small groups of known people.

“He reacted adversely to change that was badly managed”

She described how he suffered badly when change was poorly managed or prolonged. Despite knowing this, she said this was sadly a pattern on a number of situations throughout his life.

She told the court that Marcus suffered badly during covid, due to the lengthy closure of his “beloved day centre” and due to the cessation of family visits. She said these changes were “ill managed by Brandon Trust” and that staff changes at Cranwell Grove exacerbated the effects of the pandemic.

Anna told the court that eventually Marcus staying at Cranwell Grove became “unfeasible” and he moved to his final home, Cheddar Grove on 1 February 2021. She said that they were hopeful the situation for Marcus would improve “although we had concerns as it was still run by Brandon Trust”.

Anna said that Cheddar Grove had an “excellent long standing registered manager” and Marcus had an excellent key worker. Both of these staff members were nurses. She said that the staff “appeared a coherent, close knit group”, although they had to cope with staff turnover and the use of bank and agency staff.

She told the court that Cheddar Grove “felt like a home from home where the support was really caring” and where the atmosphere was of warmth and fun. She said they were given plenty of information about Marcus’s progress and they “always felt really welcomed and cared about, on calls and visits”.

Anna said Marcus appeared to enjoy his days at Cheddar Grove and his day centre was reinstated once covid restrictions lifted. Sadly, she said, two key staff members, the registered manager and Marcus’s key worker decided to take early retirement about a year after Marcus moved in. She told the court this was a situation she had dreaded “as Brandon Trust had such a poor record of managing such changes” for Marcus.

Anna said that they submitted a complaint to Brandon Trust on 21 January 2022 which encapsulated their fears that Marcus might experience similar circumstances at Cheddar Grove as they’d seen previously.

In April 2022, Anna told the court a “young inexperienced employee” was moved from elsewhere in Brandon Trust to be the new Registered Manager at Cheddar Grove. He was not a nurse. She told the court that they felt this appointment was “expedient rather than based on suitability”.

She said other long term staff began to leave and changes were evident, and that the staff group were less coherent as a group. She said Marcus seemed less responsive and less interested in them, and any suggested activities, when they visited. She told the court Marcus was “revived” on a brief holiday that he went on with herself, his sister and two members of staff from Cheddar Grove in August 2022.

She visited Marcus two weeks before the incident that happened and said she was left worried. She said there was now poor management of communication with the family over issues such as Marcus’s clothing needs and his health. Anna told the court that Marcus now had two keyworkers, who barely knew him. She also felt that regular reviews weren’t happening, and that staff were uncomfortable when asked how things were going, telling her they never really saw the manager.

Anna told the court they received a response to their initial complaint on 16 May 2022, and that they responded again on 26 September 2022. Correspondence was ongoing throughout the summer before Marcus died, and the complaint remained unresolved.

Anna said that she could never have imagined anything as dangerous as what happened on 28 September would happen. She described arrangements for Marcus being supervised around food and when eating.

She told the court that she had been told that on 28 September 2022 Marcus had swallowed items from a sensory activity at Cheddar Grove that had been set up for another resident.

“We now know this was dried rice and two conkers”.

She said this incident led to Marcus’s hospitalisation on the same day, she was not present at the time. She said it was her understanding that Laura Bolus, the activities coordinator who was conducting the activity, had gone to hospital with Marcus.

Anna told the court that she believed that Laura had been replaced by Katherine Khorsand at around 5pm. She told the court that they had discussed that Marcus “could not possibly have swallowed conkers from the activity”, although she did not know if Laura Bolus had made the doctors aware of this at the time.

She described being contacted by Cheddar Grove that day to say Marcus was in hospital for a check-up and it was “nothing to worry about”, that they would keep her informed. She said that she was concerned but not unduly worried.

She received a call from Katherine Khorsand that evening who mentioned she had concerns and asked Anna if she’d like to speak with a doctor. Anna told the court that the doctor called back and indicated that things were more serious than she had initially been told. She said that she decided to go to be with Marcus and she arrived at 23:30 that evening.

Anna said that she stayed with Marcus overnight in the hospital, that she was concerned but had “no idea there was any risk to his life”. The following day she said she stayed through the day and it took all of them to care for Marcus. Marcus’s sister arrived later that day.

Anna described that Marcus was constantly trying to remove the oxygen mask and that when he was not asleep he sat crossed leg on the bed, reluctant to lie back on the pillows. He was “very confused and evidently in a lot of discomfort”.

Anna described how Marcus deteriorated over the next few days. She mentioned being told at one point that he had pneumonia, and that he could not tolerate swallowing water. She told the court about speaking with the ICU consultant about options for Marcus whilst he was still in the A&E Department.

Anna told the court that the second time she saw the consultant later that day he advised that Marcus was not improving. There was a further discussion about Marcus being intubated and they agreed it was not a good idea for him. She described this as a crucial conversation but at the time they were in a “highly shocked state” as they had just realised how gravely ill Marcus was.  

Anna said she got in touch with a Learning Disability Nurse at the hospital on the Friday, whose number she had stored in her phone, they had met when planning Marcus’s upcoming cataract operation. She told Anna she was aware that Marcus was in hospital, and that she would come to see him. Anna recalled how she took a “completely different approach from the other nurses”, sitting down at Marcus’s level and encouraging him to handle his oxygen mask so that he could get use to it. Anna said that the ward staff who witnessed this interaction subsequently changed how they worked with him afterwards, which helped him.

She told the court that Marcus’s sister remembered that the doctor was particularly concerned that Marcus was not responding to the antibiotics and suctioning, as he had when he first came into the hospital. The doctor was of the opinion that if he hadn’t responded within three days, then the prognosis was not good, she said. Anna said that by this stage Marcus was was dependent on a high level of oxygen, and he was unable to support himself without it.

Anna told the court that she contacted the palliative care team herself as she had concerns that if Marcus was dying, they needed to be involved so that he would get all the required medication. She said that they did not work at the hospital over the weekends but there was a consultant on call for advice. She said a palliative care nurse came to visit and she said that the ward staff could increase Marcus’s medication and put him on a morphine driver if needed.

Anna said by Saturday Marcus was struggling to stay upright and was getting weaker, although he did not want to lie back. Marcus’s sister was with him when the doctor did their rounds. By this point, Anna said, it was recognised that Marcus was not likely to survive, however the hospital were still actively treating him in case he could be saved.

By Sunday, Anna told the court, Marcus was in palliative care and various people came to visit him. She said someone came to collect things from the ward, such as his wheelchair, to take back to Cheddar Grove. Katherine Khorsand stayed well into the morning after her night shift, Anna said because she recognised that she was unlikely to see Marcus again. Anna remembered how Katherine kept saying that Marcus was “a fighter” and that he might surprise them yet.

Anna told the court that staff removed all the monitors and left Marcus on a small amount of air, morphine and pethidine to keep him comfortable. Thankfully, she said, he slept most of his last day. That evening, she said, his breathing became much shallower, she said they spent time stroking his head, soothing him and singing to him while he slept. A very dear carer from Marcus’s past came to see him. Anna said that she sent the Cheddar Grove staff back as there was no need for them, although the evening carer chose to stay.

Marcus’s half sister came to see him and say goodbye, travelling from Wales, and he opened his eyes when she arrived.

“He seemed to look at us and then he was gone. He died at around 9:15 that evening”.

At that stage, as pre-arranged, Anna left the witness box and her counsel checked that she was ok. She was and wished to continue.

The coroners officer then read a final section of Anna Rose’s statement, that she said was called conclusions. She told the court that at no point that she remembered did anyone, at the hospital or Cheddar Grove staff, mention Marcus might have swallowed conkers.

“We understand from the Coroner’s Officer that the post mortem revealed Marcus had swallowed dried rice…found in his lungs and two conkers… had become stuck in his oesophagus.

This was an incredible shock”.

Anna’s statement continued by questioning whether the treatment Marcus received might have been different, or if he might have survived, if the conkers had been known about.

She said that the circumstances of Marcus’s death demanded thorough investigation of the background and context. She said that she had many questions about the sequence of events leading up to Marcus being taken to the hospital, and that she also had questions about what the hospital staff had been told.

Anna’s first statement ended by telling the court that the Registered Manager of Cheddar Grove had taken sickness leave immediately following Marcus’s death and to her knowledge was still off work at the time of her writing this statement. She said at this point Cheddar Grove were onto their second temporary manager.

Anna’s statement ended that as a family they were still in shock, about how this had come about. She said the dear and pain Marcus suffered and for him to lose his life in this manner “are beyond bearing”.

The coroner thanked Anna Rose for reading her statement. We were later told that this statement was dated 20 December 2022, and that there was an addendum in a second statement.

The coroner’s officer read that statement to the court also. It said that Anna wished to provide further information regarding Marcus in general, his experiences at Cranwell Grove, at Cheddar Grove and at Bristol Royal Infirmary prior to his death.

She told the court that Marcus was strong and physically supported himself well, adding “he was not frail”. She explained that Marcus would usually rock back and forth when he was bored or distressed, although he would sometimes also rock when he was happy, although on those occasions he would be smiling.

She told the court that Marcus was allocated 8 hours of 1-1 support when he lived at Cranwell Grove in the house, and he received 20 hours of 1-1 support when he attended Leigh Court Day Centre for 4 days a week.

She said that the move to Cheddar Grove had “paid off” and Marcus was more settled. She said that Marcus no longer received 1-1 support at home, and the support he received at Leigh Court was discontinued, but she fought for it to be reinstated. She told the court that Bristol City Council eventually agreed to restart Marcus’s visits to Leigh Court with 14 hours of 1-1 support over 2 days although that was “soon reduced to 7 hours 1-1 support due to staff shortages at Leigh Court”.

Anna said that Bristol City Council did not allocate 1-1 support to Marcus while he was at Cheddar Grove and she did not remember agreeing to this.

Anna said “several months after his admission” they received the “dreaded news” in April 2022. Marcus’s excellent key worker was retiring. She told the court that Cheddar Grove rapidly went downhill. She said that she feared this would happen due to her previous experiences with Brandon Trust at Cranwell Grove.

Anna told the court that Marcus was moved to a pureed diet a couple of years prior to his death, and he was supposed to be observed during mealtimes and where food was involved. She said when visiting she sometimes noticed that staff left the dining room and did not suitably supervise Marcus during mealtimes. She said they were stretched by the number of staff required to give 1-1 support to residents.

Anna told the court about a holiday that Marcus went on the summer before his death with her and his sister. She said Laura Bolus and another support worker called Mitchell accompanied Marcus on this holiday. Anna said that Laura was “fairly new in her dual role” at this point [we later heard when the Registered Manager gave his evidence that Laura worked as an activity coordinator and picked up additional shifts as a support worker]. Anna said Laura had never accompanied any residents on holiday before, and that she thought she felt pressured into attending, that she was overwhelmed and upset.

“Laura initially appeared nervous but was very conscientious and kind to Marcus and grew in confidence”.

Anna’s statement then discussed Marcus’s admission to the Bristol Royal Infirmary. She told the court she had received a call in the middle of the day saying Marcus was in the hospital for a check-up. She said she was not told what happened and she assumed it was a precaution.

She said she was reassured that Marcus would return him shortly and she was told not to worry. She told the court she received another message later, saying the same thing. She said she kept her phone with her, on vibrate, so she could check for updates. She assumed Marcus had returned home when she heard nothing further from anyone at Cheddar Grove, she said.

She said that it was difficult to get in touch with anyone at Cheddar Grove since there had been a change in manager, that messages were often not responded to, or calls were not picked up.

She told the court about a call she received from Katherine Khorsand that evening. She said Marcus might potentially need to stay in hospital for a while and asked if she wanted to speak with a doctor. Anna said she was now “much more worried” and she received a call from Dr Reed some time later. After that call she told the court she immediately knew she had to get to Bristol and she set about arranging that, arriving at the hospital at about 23:30.

Anna told the court that she did not receive any calls from Emily Richardson, the Learning Disability Nurse, that day (Wednesday 28 September) or the next day. She said that she first spoke with her when she called her on Fri 30 September 2022. Anna said that she told her that she was already aware of Marcus’s admittance to hospital but had not seen him yet. Anna said that afternoon Emily had visited Marcus and that led to many benefits for him, as she’d outlined in her previous statement.

Anna said that she stayed with Marcus throughout his time at the BRI, except when she left for brief periods to sleep. She told the court that during Marcus’s time in hospital she does not believe he was able to swallow any liquids, which was “not usually an issue for Marcus who needed and enjoyed drinks”.

She said that she had witnessed Katherine trying to give Marcus half a teaspoon of water as his mouth was very dry and that this led to a “very violent reaction” because he could not swallow it.

“It was like he was choking… water splattered out of his mouth”.

Anna said that Marcus’s sister, said that a doctor had seen Marcus receiving a teaspoon of water that resulted in a similar violent reaction. Marcus’s mother and sister started applying moisturising cream to Marcus’s lips “provided by the hospital, at our request”.

Anna told the court that she did not think that the hospital had the appropriate facilities to help Marcus be more comfortable, giving the example that they “did not have an upright bed support to help Marcus sit up”. She said that the staff rarely looked Marcus in the eyes, or slowed down when speaking to him.

She said this was highlighted by Emily Richardson’s “short visit on the Friday” when she took the time, got down to Marcus’s level and he “responded favourably” to the way she engaged him. Anna said, had the staff had training or advice to engage with Marcus, “or requested or had access to Emily I think Marcus would have responded to, and tolerated treatments better”.

“He needed more time, engagement and reassurance from staff”.

Anna told the court that she first found out Marcus had swallowed conkers when she received a call from the Coroner’s Officer Linda brown.

She said she was “shocked by this discovery” and that she “agonised over how that felt for Marcus” during his time in hospital at the BRI. She told the court that she did not know if anyone at the hospital had been warned of “the possibility of conkers” and she did not know whether staff knowing about conkers would have affected the treatment given to Marcus.

Anna said that Katherine Khorsand had told her, after Marcus’s death, that in her overlap with Laura Bolus (on the day Marcus was admitted to hospital), Laura had surmised with her that Marcus surely could not have swallowed any conkers.

Anna told the court that she had only discovered there were conkers in the bowl, alongside the rice and a spoon, left on the dining room table at Cheddar Grove, when she was reading documentation for this inquest. She said prior to that they could only go on what they had been told personally, which was that Marcus had access to a bowl of craft dyed uncooked rice, while unattended.

This second statement was dated 17 November 2023.

Court then adjourned for a mid-morning break at about 11:20.

[I’ll report the remaining three witnesses from today when I can. With thanks to those reading, sharing, supporting and funding my reporting].