Marcus Hanlin’s inquest – Nick Stevenson, Bristol City Council

After a mid morning break on Day 1 of Marcus’s inquest, Nick Stevenson was called to the stand. He gave an oath and confirmed his full name for the court’s record. He told the court that he was a qualified social worker and he was registered with Social Work England.

“Unfortunately, I did not know Mr Hanlin, but at the point of time when we were asked to provide a statement in relation to this inquest, the Team Manager responsible for covering the area was off sick, so I was asked to work through our records and provide statements that have been provided to yourself”.

The coroner said that this was not a memory test and took him to his two statements that she said were in Bundle 3. She said that Mr Stevenson had been asked to respond to certain questions that had been raised, that she would go through the questions and he could go through what evidence he was able to find from the file.

She asked the first question, why the level of care for Mr Hanlin was reduced, before stopping herself and checking with Marcus’s family how they would like him referred to in court. Checking whether they would prefer Mr Hanlin or Marcus. His mother replied Marcus.

Coroner: We’ll all try to remember that going forward. Why was Marcus’s level of care reduced?

NS: From the move between Cranwell Grove and Cheddar Grove, my reading of support plans was it wasn’t…  different kind of set up, moved from a Supported Living environment, what we were commissioning for the majority of his care and support was 1:4 staffing ratio.

When in the move to Cheddar Grove BCC (Bristol City Council) were commissioning a staffing ratio of 1 staff for 3 people living there. My understanding was that was not a reduction in the core level of care.

C: OK, thank you, next question… what was the consideration for how Marcus would be kept safe, given the need for constant supervision around food/food like items, if staff were responsible for three at one time?

Mr Stevenson told the court that there was “no reference on our system for the need to constant supervision around food and food like items”. He said that there was reference to risk of aspiration and a Speech and Language Assessment, “we did not have a copy of that report on our system”.

He told the court that it was also referred to in a number of letters received from the Community Learning Disability Team. He said there were references that Marcus liked to eat and eat fast at times. He told thee court there was also reference to “at a time in his history his teeth had been removed”.

He then said something else that I could not hear. He was sat side on to the microphone facing the coroner, so a lot of what he said was hard to pick up.

The coroner’s next question was what monitoring was carried out to ensure the ratio of care staff to residents was being implemented.

“The Care Act requires we maintain regular reviews of commissioned packages of care, and in April 2021, a review was undertaken at Cheddar Grove”.

He said something about a subsequent annual review [I think, again hard to hear] which he said meant that they maintained responsibility, but there was no longer an allocated worker responding to specifics of the case, which he said, was standard process.

He continued, telling the court that once Marcus had been at Cheddar Grove for a period of time, working with Marcus’s family, the practitioner at the time had been to request funding “which led to the reinstatement of some of the hours previously at Leigh Court, which was the day care provision”.

Mr Stevenson then referenced a safeguarding enquiry that was conducted in the second half of 2021, “following an incident where Marcus was physically dragged from the kitchen because he didn’t want to leave”.

“That went on for a good few months [safeguarding enquiry], again during that period there was no concern raised back to reviewing team that there was a concern about the ratio of care staff.

I would say we are, we aim to review ongoing support plans, ongoing cases, work with families and individuals to review their care on annual basis. A review was set for April 2022… lack of available staff meant that review had not taken place by the time of Marcus’s death.

When I wrote this original statement, I was not aware of the complaint that had been submitted, could find no record on our systems about complaint being raised about the standard or level of care at Cheddar Grove.

Subsequent to submissions from the family I found a complaint, which does relate to a concern [barely hear] his mother referenced in her statement earlier on, this was investigated in the standard way, would be by Brandon, who submitted their report, the family then submitted their response. At that point the LA (local authority) would look and try to understand the outcome of that, that was shortly before Marcus’s death, at that point in time had been no formal… [cant hear]”.

The coroner’s next question was “what checks were made whether the reduced care and support was adequate to keep Marcus safe, anything further to add from what you’ve said?”. I couldn’t hear Mr Stevenson’s response.

The coroner then asked a question about the reduction in hours of 1-1 support for Marcus.

“Some of this stems from changing the provision commissioned for Marcus from Supported Living to a nursing care placement. Standard expectations of a nursing placement, is they’re fully able to meet the entirety of an individual’s needs. Whereas care and support provided within Supported Living is more frequently on a basis of individualised areas of need, for example, I know when Marcus was at Cranwell Grove, there was 1-1 support to support him when he was out of the property, going for walks, going shopping, activities outside the property… that was variable, understand from some case records it wasn’t always provided, particularly if Marcus refused or was understood to refuse to participate.

We, when we sought funding agreement for the placement at Cheddar Grove, there was a record of fairly significant dialogue between the practitioner at the time, and the Operational Manager who authorised funding.

Around both what should be ordinarily provided by a residential nursing provider, and whether or not a significant change moving from Cranwell Grove and all its problems it had at the time, Marcus was experiencing with the changes there, to a new placement, whether or not continuation of day care would be more unsettling or not.

That was a question that was raised, it was largely unanswered.

The decision about funding was that needed to be an early review, at 4 weeks, with a request come back should there be an ongoing need for support for Marcus to attend… [can’t hear].

I understand from notes Marcus’s family were consistently advocating for that… worked with [can’t hear] practitioner to support a request for that, which was funded for 2 days a week. I think, my reading of the record was 2 days a week, was to be reviewed at some point in time, because of the provision, level of provision at Cheddar Grove, as opposed to Cranwell Grove, it would hopefully be sufficient.

All the records, 1-1 support, those are all around supporting Marcus to fully participate in activities, to get the best level of engagement and gain benefit from those, could find no record in the records I had access to, of that being a risk management level of support, although I think [can’t hear] 1-1 support would manage risk”.

The coroner asked if there was anything else he wished to add around 1-1 support, there was not.

C: OK, then there was a final question I believe around whether you had any knowledge around staffing levels and under-staffing levels?

NS: Not when I first answered ma’am and there is a line in part of the complaint, which I was then shown, with the family stating the home had been chronically understaffed since Marcus arrived in February 2021… reliance on bank and agency staff…  I can’t find a record other than that of an alert being made, can’t see any reference in the safeguarding report undertaken, neither in reports with the psychiatrist who reviewed Marcus on a 6 monthly basis whose response was he was settled… [can’t hear]

C: OK, thank you very much, I don’t have any further questions. Mr Lewis.

OL: Good morning, I ask questions on behalf of the family… bundle 2 please, the records bundle, page 528. Do you have that?

NS: I do yes

OL: This is a document, my understanding is one on 528-536 is a support plan review and turn to page 535, understanding of this is an old one, 2017. Dates are there?

NS: Yes

OL: Commissioning and costings there. Next one, 537

NS: Uh hum

OL: It says Your Support Plan?

NS: Yes

OL: This is Bristol City Council care and support plan for Marcus?

NS: Yes

OL: The date of that as far as I can tell, is p551, bottom, mental capacity assessment, 16 October 2020?

NS: Yes

OL: Best Interests 5 November 2020, over the page 552, form completed 17 December 2020. Is that right?

NS: Yes

OL: As far as I could find this is the only care and support plan we have. My questions is, is this the most up to date care and support plan Marcus had?

NS: I don’t believe it is.

OL: Well I certainly haven’t seen one. Are you able to obtain that?

NS: Yes, that’s on our system and can be provided to the court.

OL: Madam I don’t know whether that has been previously disclosed by Bristol City Council and not disclosed to IPs?

C: If it is not disclosed I very much doubt we have it

OL: From your memory, or is it unfair to ask questions from your memory?

NS: You can ask, if I can answer I will.

OL: Does it say anything about the 1-1 provision and what was commissioned?

NS: It references in service support on 519 at that point in time was service commissioned from Freeways Trust, which was for 1-1 support. Freeways Trust provided the day care at Leigh Court, that covers that.

On the other aspects of that, I understand that Sleep-In DPS would refer to theoretically a 1-4 sleep in, the Supported Living DPS would be the shared care element, I would imagine, the Supported Living DPS Intermediate 2 Level would be the 1-1 support for those 8 hours, or at one point I remember it being 16 hours to support Marcus to partake in activities out in the community.

OL: OK, on page 550. The completed box there, that’s the request made to move to a specialist residential care placement, future plans?

NS: Yes

OL: Bottom of that box, under bold writing says including 30 hours shared support, no 1-1 hours, Brandon Trust say in nursing home they don’t have 1-1, if needed will increase. So at least a flag in there of the possibility of 1-1?

NS: Yes

OL: But we don’t have the last care plan, so we don’t know whether that was, alright. Can I just turn my back for one moment. [He moves to the row behind to speak with Marcus’s mother Anna]. Thank you, no further questions from me.

At this stage the coroner said that she wished to pause to be clear whether Mr Lewis was asking the witness to obtain the document and provide it. Oliver said that his submission was that it would be very helpful to have the care plan that was in action at the time.

The coroner checked whether the witness had a laptop with him, and whether that might be something he could provide over the lunch break. He did and thought he could.

There were no questions from Mr Haddon for UHBW, none from Mr Brownwell for Brandon Trust pending disclosure of the care plan. There were no questions from Mr Cousins for Laura Bolus, and none from Mr Lindsay for the SWAS.

The witness was released to make his way to the front of the court where there coroner said someone would be able to assist him in printing copies of the plan.

The court then moved on to the next witness, Katherine Khorsand, before Mr Stevenson returned after lunch to complete his evidence. For completeness I’ll finish my report on his evidence here, now.

Mr Stevenson was recalled to the witness box shortly before 12:45. Mr Lewis asked for time to read the document and take instructions before he was questioned, the coroner said that she wished to take him through his evidence about 1-1 first and then they could break.

C: First of all, what is this document?

NS: This document is a support plan, dated from March 2021, its the penultimate support plan we have for Marcus, is a further one we used to close down all services at the time of his death. It shows we changed two services we were commissioning by Bristol City Council for Marcus.

Completed by a social care practitioner. On the third page it starts with a summary of background and what’s going on with decisions around Marcus moving to Cheddar Grove, is on page 5, and throughout it there’s fairly strong advocacy of the need for ongoing day care input from Leigh Court which Marcus found beneficial.

Reference to the CLDT (Community Learning Disability Team) staff saying for Marcus to get benefit from activities, having 1-1 support is really beneficial for that. Then page 8 onwards, page 9 onwards, you get the detail of the support plan.

I would point out if I was authorising this I wouldn’t have passed it. It says unmet in the top column, we’re clearly providing those services. It’s a tricky thing to do in the system, if concerns about that, clear areas of support are being met [I think he said, he turned away from the microphone to address the coroner which made sound difficult].

Then on page 13, page with 2 boxes in it, second one clearly say Marcus needs his main meals prepared for… needs support with this, finds pouring hot liquids difficult and risky… Marcus also needs careful supervision when eating as does not chew well and is said to be at risk of choking. Direction for staff to continue to support Marcus with clear direction… service provided by Brandon Trust as core support, or by Freeways when he is with them.

The further part I thought was possibly useful was page 17, which is 3rd printed page from the end, which references a summary of the request, identifies it includes provision by Cheddar Grove with 2 additional days now on the support plan and funded at Leigh Court. That’s saying what the provision is.

C OK, thank you.

NS: Can I just say on the back of that, I don’t recall in preparing my submission a request to provide documents, and obviously we would have done. Also I’m aware of family participation in reviews and providing comments, so I’m not sure why you didn’t have a copy of this, is a requirement we send copies of support plans to individuals if they have capacity to manage them, or to their representative or appointee and also to providers.

There was then a further timetabling discussion where it was agreed that the witness would be recalled after lunch for any matters arising, once interested persons had a chance to read the plan and their counsel had a chance to receive instructions.

The coroner apologised for the lack of facilities and said that people would need to go off site for refreshments, so she would allow an hour for lunch and hope that people would make it back.

Court was adjourned at 12:50 and resumed at 2pm. Mr Stevenson was recalled for a second time.

Mr Lewis said the family had no questions in relation to the care plan and thanked him for providing it.

Mr Hadden for UHBW had no questions.

Mr Brownhill, for Brandon Trust followed.

IB: Briefly, confirming in terms of commissioned hours for Marcus, 1-1 was simply at the day care provision?

NS: Yes

IB: The remainder of commissioned support time was 3-1 as part of core hours he received at Cheddar?

NS: Yes

IB: There was nothing, you answered earlier to the coroner, was implicit level of risk management in respect of commissioned care hours?

NS: Yes

IB: Nothing in the support plan around particular risk of ingesting objects?

NS: The only reference was the one I mentioned earlier, supervision when eating. Nothing specific, would have been quite hard to write that in without a prior history.

IB: Thank you.

There were no questions from Mr Cousins for Laura Bolus or from Mr Lindsay for SWAS.

Mr Stevenson was released at 14:01.

[I’ll try to report now on the witness we heard before lunch, Katherine Khorsund, and the witness after lunch, Keaton Pullen].

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