Marcus Hanlin Inquest – Laura Bolus

The second witness on Day Two of Marcus’s inquest was Laura Bolus. The coroner called her at 10:17. She gave an affirmation and confirmed her name for the record.

C: What was your role at the time?

LB: Activities coordinator

C do you need your statement to refresh your memory or do you remember these events quite well?

LB: I think I should be OK

The coroner reassures her it is not a memory test and that she can refer to her statement if she wishes or needs to.

C: Your statement said you commenced work for Brandon Trust on 15 September 2021, initially part time, then you became full time from June 2022, your job description at that time was Activities Co-ordinator. What was your role to do, as such?

LB: So, it was to get to know the residents, what their interests are, their backgrounds, trial activities with them, plan and deliver that inside the home and out in the community.

Part of my responsibilities would be driving the van, supporting people on trips out and providing feedback on the activities that worked. Working with others in the team, we’d have a timetable for like themes and activities, like person centred for each individual, and their various support needs as well, yeh

C: OK. So how well did you know Marcus?

LB: I knew Marcus well, I supported him a lot when I was at Cheddar, and also supported him on holiday with family in August 2022. Um, and on a 1-1 basis with Marcus as well, out in the community, as well as at the home

C: So your role as I understand it shifted a little bit from Activities Co-ordinator to more of a Support Worker as well, is that right?

LB: It was, during short staffing, with sometimes having that covid breached in the home, I would offer support where needed. So, the Support Worker role with personal care and medical assistance, not the nurse side of it but picking up medication when needed and those sorts of Support Worker responsibilities, did get put on me while I was there at the home. We work as a team, we all help each other when we can, so lines got blurred a little bit. I did ask for my role to be more defined, Activities Co-ordinator was the position from the beginning.

C: In your role then, which included on occasions more of the Support Worker role, what sort of training did you have to carry that out, do you remember?

LB: There was an Emergency Life Support Training, another word for First Aid Training, that I believe all people working in the setting would have done that. And um, manual handling as well, I did have that. That was needed for when hoisting and transferring people from their wheelchairs to beds as well, so I completed that training. And yeh, I can’t recall others.

C: OK, so you said that first aid, is that right?

LB: I believe so, yeh

C: Did your first aid training include what to do in the event of choking? Do you remember that?

LB: Think so, yeh, I think it would of

C: So what did you understand about Marcus and food?

LB: Umm, that Marcus was urgh, on a pureed diet. Um, I believe it was Level 4, and meaning he could only have um certain textured food, um, but this wasn’t always the case, this was regularly checked with the SALT Team that come in and evaluate on his eating and drinking.

So when I would support Marcus with his food and drink would make sure it’s the right level of pureed for him. He didn’t have any teeth so you know, it’s a risk of that.

And he had his own, his vision wasn’t great, and because of his like dementia and autism, he had bright red cups and bowls and plates and things he’d use for eating, that we took on holiday as well, so he’d know what was his.

C: OK, thank you. So was Marcus, I just want to talk about the sensory activity you set up on the day. Before we get to the day, had you done sensory activities before when Marcus was in the room for example?

LB: Yes there was a sensory rice dish I had in July, that was in the home, and it had blue and yellow rice with shells in with a spoon that you’d fish out the shells of the rice. That was in the home over the summer period, for a beach theme. We had a beach theme party for Marcus in July I believe it was July, maybe June, around that time. It was one of the things we had out that day as well.

C: When you said you had that out, what do you mean by that?

LB: We had it in the dining room, where people would sit, we would do activities mainly in the dining room.

C: So that activity, with the shells, and the blue and yellow rice with the spoon. When you say that was in the dining room, do you mean it was left on a table, on the side?

LB: When not in use it was left on the bookcase shelving in the dining room.

C: On the shelving, because shelving can be this high, that high [indicates with her hand from the floor], 7 foot tall, when you say on shelving, where was it on the shelving?

LB: It was on like the middle shelves.

C: Middle shelves. Marcus would walk around, that’s right isn’t it, he was able to walk around the home?

LB: Yes

C: So it was within reach of him at all times you mean?

LB: Uhh, yeh

C: And had Marcus ever, previously when you were dealing with the shells activity, if you like, was Marcus involved with that activity before?

LB: He’d been at the table while we were doing it, it mainly worked that activity with [withheld], she loved picking the shells out. Sometimes with an activity around the table people wouldn’t get involved, would be something else for them to engage with … Marcus had been around it, but not fishing them out himself.

C: So when you say he’s been around the rice and shells activity, is it a small table, 6 or 10 foot table? Or a small table?

LB: It could fit 5 people around it with wheelchairs

C: When this activity was around the dining room before, did Marcus ever show any interest about eating the rice?

LB: No

C: The conkers. The conkers were as I understand it, picked up on a previous outing, is that right? How did the conkers come into it?

LB: Yes I know I picked some up on walks around, and other employees that took people out on walks would collect them as well and bring them back to the home, with the intention of doing activities with them.

C: Yes, when the conkers were brought back to the home, where were they put?

LB: We had them outside in the garden, on the table. It was that week or the week before even, and yeh, they were in a bowl or on something on the table.

C: And is the bowl, and the table, again is it accessible to residents at that time?

LB: Um, 5 out of the 7 were wheelchair users so couldn’t get to it

C: Was the table accessible to Marcus?

LB: Um yes

C: So in the week or so, I’m assuming the conkers were in season, the incident was in September, so in the lead up to this incident the conkers were obtained I’m assuming?

LB: Yes

C: So, conkers picked up, out outside in a bowl on a table and Marcus could go out in the garden?

LB: He could go out in the garden yeh

C: And had Marcus ever been involved with collecting the conkers on any trips?

LB: I can’t remember to be honest

C: Do you think it’s likely he was, or unlikely?

LB: He may, yes, he may have been I just can’t remember if he was.

C: Did Marcus go into the garden very often?

LB: Yes, we would tend to use that space with the residents when it was nice, it was a really nice garden. Marcus would like to be around where other people were as well, so he was quite keen to be outside. Yeh.

C: The sensory activity you set up, was it only set up on that day or was it set up before that day? The rice and conkers?

LB: I don’t recall bringing it in that day, I think I had it already there but I can’t quite remember that information.

C: So you don’t remember when you put it together?

LB: No

C: Would you usually put it together at the home though?

LB: I dry out the rice with the food colouring to make it the bright colour, I did that at home.

C: OK. So that was at your home?

LB: Yes

C: Then you’d take it in?

LB: Yes

C: Then the conkers though would come into it from?

LB: The home

C: Yes. So, with the activities, the rice and shells, and the conkers and the rice. Were, because these were accessible to the residents then, it wasn’t just an activity locked in a cupboard and brought out, it was available to the residents if they wanted to. Put it this way it was available to Marcus if he were able to access it?

LB: Yes, yeh

C: Were you ever told, or asked or requested to put the activity somewhere safe, away from Marcus?

LB: No

C: Did you ever consider yourself, before these events, putting it away somewhere safe away from Marcus?

LB: Urgh no, I believe where I had it wouldn’t have been a risk.

C: Sorry?

LB: I believe where I had it wouldn’t have been a risk.

C: Why was that?

LB: I didn’t see it as a risk for those that were in the wheelchairs, and I didn’t see it as a risk for the other two that weren’t that could walk freely, Marcus and another resident.

C: You said you were aware Marcus had a diet where he was only able to eat pureed food?

LB: Yeh

C: Did you not see this as being a risk then to Marcus?

LB: No

C: Why is that then? When its rice? I appreciate it isn’t, its uncooked rice.

LN: It was bright colours, it was bright yellow and blue for the beach one, and pink for the autumn one for conkers

C: So you say in your statement on 28 September 2022, the activity started around 11:30, in the morning, just before lunch. Pink coloured rice placed in bowl and conkers also placed in the bowl. Do you know how many conkers were in the bowl?

LB: I don’t

C: Roughly?

LB: Um, five to seven

C: Do you know what sort of size conkers they were?

LB: Yeh, just all conker size, I don’t know

C: Mixed sizes would you say?

LB: Yeh there was no obviously larger than others, just all medium sizes

C: How big was the bowl?

LB: Umm, it was about that size [I can’t see what she indicates] a bit larger than a standard cereal bowl.

C: Larger than what?

LB: A cereal bowl

C: As large as that? [She holds up an A4 pad]

LB: A little smaller

C: Half the size of that?

LB: No

C: So, three quarters of the size roughly?

LB: Yes

C: Was it a deep bowl or was it a shallow bowl?

LBL It was a little bit deep, about that height [can’t see]

C: Roughly, 5 or 6 inches or 8, it’s hard to tell from a distance

LB: 5 inches

C: That jug?

LB: Less than that, about where the line is,

C: OK [I can’t see what that equates to, apologies]. Was it glass, was it plastic?

LB: Plastic

C: See through? Coloured?

LB: White

C: Alright, was there glitter in it? There’s reference to glitter?

LB: No

C: There wasn’t glitter

LB: No

C: Alright, can you just take me through then what happened for the day, the rest of the day, I’ll leave you now to take me through it

LB: I was in the dining room, with

The coroner interjects to ask her to go slow, so that people can take notes, asking her not to go too fast.

LB: I was in the dining room with Marcus, [withheld 1] and [withheld 2], all residents at Cheddar. And I had the activity out, I was doing the activity on the table with them all, um, Marcus was watching, [withheld 2] was there, and [withheld 1] was fishing them out and putting them into another bowl, or onto the table, I can’t remember now what we were using. Fishing the conkers out the bowl, then it was discussed that people were going to go out for a walk. [Withheld 1] went, another support worker Laura, agreed to take [withheld 1] out on a walk, so we’re getting her ready, and [withheld 2] went somewhere, I’m not too sure, not sure when she left the room.

I remember talking to Sue, I think earlier that morning, about making sure everyone has got appropriate winter clothes with hats and gloves, I remember supporting Marcus earlier that week, his hands were really cold and I couldn’t find any gloves. So, making sure every resident had that, was speaking to Sue about residents I had, so went to check [withheld 3]’s room and see what he had or might need.

I came back in a moment or two and noticed the conker dish had been moved and it was sitting where Marcus was sitting. It wasn’t there before, it was on my side of the table … so I couldn’t see Marcus where he was sitting, I went to see where he was. He was sitting on the floor in the hallway of the home, nothing seemed odd at first, but I wanted to double check, so I yeh, observed him, but went straight to Sue and said I think this has been moved, no one else would have moved it and its where Marcus was sitting, I think he might have had some by accident. There was also then rice and conkers on the floor, which made me think it had been, moved, knocked or something has happened.

We both observed him together, I thought it might be best give him a drink, so if he had something stuck it would help bring it back up. He did start to spit little bits of, like, um like pussy bits of white, the rice bits up, it was sort of slowly coming out of his nose.

Shabeena was made aware at this point to call an ambulance for further assistance, at that time myself and Sue were just with Marcus supporting him, going to the toilet and keeping him stable, checking in with him before the ambulance came.

Paramedics arrived, we’re sitting in the garden with him, he’s clearly pretty flustered, and I then went in the ambulance with Marcus to hospital.

C: OK, so you started the activity about 11:30. Do you know what time it was when you started to get up and help sort out the winter clothes?

LB: I don’t know what time it was, but I wasn’t out the room for longer than 2 minutes.

C: How can you be sure it was 2 minutes?

LB: Because of what I did when I went in the room, when I checked the clothes, it wouldn’t have taken that long.

C: Do you know how long you were doing the activity for?

LB: Umm no. not long. Probably about 5 or 10 minutes.

C: 5 or 10 minutes

LB: Yes

C: Marcus was how far away from the bowl when you were doing the activity?

LB: He was the other side of the table, furthest to the wall, I was opposite [withheld 1], don’t know how far that would be, but it wasn’t in reach of Marcus when I left the room.

C: So, we know that Marcus interacted somehow with the bowl. How do you think he did that? You were with him at the table and were first to go back into the room, what did you think happened?

LB: He had maybe got up off his chair and brought it to where he was sitting, or he might have leaned over. I didn’t think it was in reach of that, I just know it was not in the place where I left it and it was by his red cup where he was sitting.

C: And you describe the other resident was fishing out the conkers, what were they using to fish out the conkers?

LB: A spoon

C: And the conkers that were fished out, do you know where they were put?

LB: Yeh I can’t remember, but I think we might have put them in another dish, or on the table.

C: Was that, were the conkers put any closer to Marcus do you know, can you remember?

LB: No, they wouldn’t have, I wouldn’t have thought so.

C: You don’t know, you don’t remember?

LB: No

C: So, you say you shared your concerns with Support Worker Sue Watts and it was Sue that suggested the lemonade?

LB: Yes

C: What was the timescale of all of this happening? Do you remember any of that? This happened over a period of half an hour, or minutes?

LB: Of what happening, sorry?

C: Of you going back in the room, finding Marcus, getting Sue, the lemonade, how quickly is all this happening?

LB: That’s happening quite quickly, I saw Sue was with [withheld 4] in the room next door to the dining room, told her as soon as I saw the bowl had moved and I seen Marcus, although didn’t see anything obvious, I had my concerns so I went straight to Sue

C: When you spoke to Sue, did you make Sue aware of what had happened, with the conkers and the rice?

LB: Yeh

C: So, the effectively the nurse on duty Shabeena, did you call her or how did she become involved?

LB: I can’t remember, I can’t remember who, but I remember her being there, one to be made aware and two to call the ambulance or support with next steps.

C: So did you perform any First Aid on Marcus?

LB: No

C: So when the paramedics arrived, what did you tell the paramedics?

LB: From my memory, I explained we were doing the activity with rice and conkers, and we believe he has ingested some, not too sure how much or what, but he was spitting bits of rice back out, which basically confirmed he had had some. I remember them saying his oxygen levels are low so we’ll have to take him to hospital, which I supported with.

C: Did you show the paramedics the sensory activity?

LB: I don’t think so

C: So Marcus is taken to hospital in the ambulance, did you go in the ambulance with him?

LB: Yes

C: So, in the back of the ambulance is there a conversation going on?

LB: No, there was Marcus in sort of the bed restraints and he was not understanding and trying to get out, so I was just supporting Marcus with trying to keep him as calm as possible, and obviously the ambulance is going really fast everywhere. I don’t remember any conversation happening with the lady who was just typing up notes on the computer whilst the ambulance was moving.

C: OK, so you get to the hospital, can you take me through a little more about what happened when you got to the hospital?

LB: I remember going through, like doors with Marcus, and going into the Intensive Care Unit. And waiting with him. Until like professionals came to sort of help. Um, and yeh, just sort of being with Marcus

He was foaming every now and again, slowly from the mouth, so I’d be supporting him with that, and him going to the toilet, until. There was a lot of waiting around, a few different people came, asked like questions about what had happened, I said about the rice. That its uncooked rice, its dyed inside a vinegar and colouring.

C: So when anyone asked you what had happened, you said about the rice and the conkers, or just the rice?

LB: The questions were around the rice more at the hospital, I don’t recall mentioning conkers to a professional at the hospital

C: Can I ask why you didn’t mention the conkers then?

LB: I answered any questions the professionals were asking, I assumed it wasn’t their interest, the conkers wasn’t their interest of what they needed to see to

C: Sorry, say that again

LB: I wasn’t, I would have assumed the information would have got relayed from the initial paramedics. So I, I didn’t feel the need to explain it, like everything to every professional that came. There was quite a few different people trying to figure out what area to look at, whether it was ear nose throat specialists, or if it was going to be a chest issue.

C: OK, can I just ask you to pause a moment then. Did somebody say to you, tell me what happened?

LB: No, not at the hospital. They were asking more questions around the rice.

C: So no one at the hospital, none of the professionals, asked you what had happened to Marcus?

LB: To be honest it was a really stressful situation, I kind of did rely on the hospital, that they were figuring out what to do with the information they’d been given. I was just supporting Marcus, he was wanting to sit in the middle of the floor in ICU and stuff, I just can’t remember what was said. I just remember answering questions, but as and when people spoke to me.

C: So you answered questions if people asked you. What I’m trying to understand was you weren’t asked about what had happened?

LB: I don’t know, I can’t remember what was said

C: You can’t remember?

LB: No

C: So is it more accurate that you can’t remember, or is it more accurate that you weren’t asked?

LB: Its more accurate that I can’t remember

C: If you’d have been asked tell me what happened, what would you have said then? What do you think you would have said?

LB: I would have said what happened.

C: Which is?

LB: That there was a sensory rice with conkers in, and we were doing an activity at the home, and we think Marcus has had some, and we don’t know how much.

At this point a member of counsel interjected to say that they couldn’t hear.

LB: There was a sensory activity with rice and conkers, we believe Marcus has had some, but we’re not sure how much.

C: Um, I don’t know if you were in court yesterday?

LB: No, I wasn’t

C: One of your colleagues was in court yesterday Katherine Khorsand, she was saying when the x-rays were taken, you were there, the x-rays were put up on a screen and you made a comment. Do you remember that in the hospital?

LB: I remember being with Katherine when the x-ray was done

C: Do you remember seeing the x-rays? I’m not expecting you to analyse the x-rays, I understand you’re not a radiologist, do you remember being there when they were put up?

LB: Yes

C: Do you remember saying anything about what you saw?

LB: I don’t remember what was said

C: Well what she said, I’ve made a brief note, what I have written down is she said ‘there was a white cloud, was a bit fuzzy on the screen, down near the bottom was a round ball’ and you said words to the effect of, ‘do you think that’s a conker?’


C: Do you remember that?

LB: I don’t remember

C: OK, so again, is it just you don’t remember, you may have said that?

LB: Yes

At this point the coroner said that she would go back to Laura Bolus’s statement because there were a couple of other things that she wished to cover off. She started by asking if she was aware of the SALT Guidelines in place for Marcus, and Laura says she was.

C: You were aware he had to have pureed food?

LB: Yes

C: Were you also aware one of the phrases in the SALT Guidelines is about unadapted food. Do you know that phrase at all? Is it a phrase you’re aware of?

LB: Not unadapted

C: So what are you thinking when I say that?

LB: I don’t really know what that would mean

C: OK. In the kitchen area were there any steps taken to support Marcus from not eating items he shouldn’t

LB: So where food was prepared in the kitchen was a gate with a lock so Marcus couldn’t walk fully into that area, and there was locks on the cupboards and fridge in the kitchen as well.

C: And was that all for Marcus?

LB: Yes

C: You also say in your statement it was known Marcus was drawn towards food which could cause risk in the kitchen area. Did you ever see any examples of that yourself?

LB: If food was being put in front of another resident, he’d be interested, but they did get food at the same time. If food was prepped in the kitchen past the door, Marcus would be standing there and he’s just keen, yeh he enjoyed his food, I saw that, in loads of obvious ways.

C: You also say in your statement, same paragraph, ‘he would not have the capacity to know if food items were cooked or whether he’d be able to chew or swallow appropriately, this risk was known to all staff’. Is that correct?

LB: Yes

C: That’s correct?

LB: Yes

C: In paragraph 52 you say ‘concern in relation to food uncooked and unpureed’ is that right?

LB: To the bit before?

C: Your statement at paragraph 52 says ‘the concern was in relation to food that was uncooked and unpureed’

LB: Yes

C: Yes. So, did you see the rice that was in the activity, as uncooked and unpureed food?

LB: No

C: Why not?

LB: I mean, I just, I didn’t at the time.

C: OK what I’m going to do is allow some others to ask questions and might come back to you at the end. Mr Lewis.

It was then over to Oliver Lewis, who asks questions on behalf of Marcus’s family. He started by introducing himself and checking whether Laura Bolus required a break, she said she was fine to continue.

OL: I’d like to ask you some questions about your induction and training, then move on to look at care plan documents the coroner has referred to, then ask some questions about staffing, then about the events of the 28 September 2022. Is that alright?

LB: Uh hum

OL: There’s some bundles over there, could I ask you to get the one that says Bundle Number Two please

[She does]

OL: Roughly halfway through that huge bundle, if you could turn to page 390. Got it?

LB: Yes

OL: Is this a document that’s familiar to you?

LB: Yes

OL: Could you explain what it is please?

LB: So, this is the induction that you go through for the first 6 months from when you start with Cheddar and Nicola Webster was my manager at the time, who carried that out with me.

OL: It’s called the Cheddar Grove Service Induction Passport. It’s in relation to each staff member, this is yours?

LB: Yes

OL: Says you started 13 September 2021 and due to end probation period in April 2022?

LB: Yes

OL: If we go through pages, some introductory pages, then page for each of the residents of the care home?

LB: Yes

OL: Marcus’s page is on page 397?

LB: Yes

OL: Some bullet points on left column, support plans, risks assessments, daily notes and so on. The next column, dates first shown, most are the 6 January 2022?

LB: Uh hum

OL: So that’s roughly nearly 3 months after you started? Is that right?

LB: Yes

OL: And what does that date indicate? For example, first one, is not 6 January 2022, that’s 14 September, the day after you started? Is that right?

LB: Yes

OL: What does that indicate in relation to support plans?

LB: They all have a, so it’s a Plan for Life, but the Plan for Life files is also on there. So yeh. I can’t.

OL: The column title is date first shown?

LB: Umm

OL: Is that 14 September 2021, is that the date on which someone, a manager showed you Marcus’s support plans. Is that what it means?

LB: From my memory yes

OL: OK, you were shown support plans on the day after you started working in the care home?

LB: Yes

OL: Can I take it all the rest of them, apart from medications which is not dated, 6 January 2022 is that the first time you were shown those other documents?

LB: No, I’m pretty sure I’ve looked at them before, it might have been the 6th was when I signed it off with my manager, as that date, not when first shown although that’s what the title of the column says

OL: Next column says date of competence and assessor sign. In relation to Marcus’s and the other resident’s whose names I’ll not read out, those two columns are blank, why is that?

LB: I’m not sure

OL: Is your evidence that actually, the 6 January 2022 should probably be the date of competence? Is that your evidence, you’re saying you were shown those things when you started, signed off with your manager, the assessor on 6 January 2022? So should those dates be in the column along?

LB: I would say so, I’m not sure if the other parts got signed off on the online part.

OL: Yeh, OK. When you were looking at the care plan including SALT Guidelines, the risks assessments and so on, was it this written system or the online system or a combination of both, that you and your manager were using?

LB: Umm, so I remember Nicola having, doing the entry online while we’d go through.

OL: OK. Can I ask about the words that are written, under bullet point, any other identified needs on page 397 in relation to Marcus it says ‘careful with food and activities’. Do you recognise that handwriting?

LB: Yeh that’s mine

OL: That’s yours, ok. Why did you write that there?

LB: So, this was, my understanding for me to add any notes, when I started, for what I looked for, for my understanding of getting to know the residents from the information I was learning. So the notes I’ve put in the comments are stuff that would be, that I’ve learnt that the residents might enjoy or about them that I need to consider. So, this my understanding, was for my personal use.

OL: Uh hum, in the first 6 months of your probation period, for your induction, for you to get to know the residents and how care should be delivered to them?

LB: Yeh and the activity side of things, in notes I’m writing activity suggestions.

OL: Yes. It says ‘careful with food and activities’

LB: Yes

OL: Just looking across other pages, Marcus, that’s the only resident who has that written ‘careful with food and activities’. When you wrote that, what did you have in mind when focusing on activities?

LB: My notes on all of them would be from an activities perspective, that would be something I’d read from information of starting at the home, that’s something I need to consider when doing activities, that’s why I would have noted it down.

OL: What does it mean to be careful with Marcus’s activities? Careful about what?

LB: I guess, the obvious. Being like, being supervised when with an activity, yeh.

OL: To be supervised?

LB: With an activity, yeh

OL: Underneath that, in the box, comments box/any other identified needs. You’ve put two bullet points, one is smoothies/food related activities and one is sensory activities red cup/yellow cup. What is smoothies/food related activities?

LB: Marcus enjoyed his food, we got loads of fruit in, made smoothies, we got an ice cream maker, had chocolate fondue, activities like that. Also done potato printing with Marcus before, take potatoes and shape and make prints, that was something I’d support with Marcus.

OL: You’re saying quite a lot of activities for Marcus that involved food or food items?

LB: Yes

OL: Why was that?

LB: From my understanding, and others at the home, he enjoyed food.

OL: He was a foodie?

LB: Yes, he was a foodie

OL: He enjoyed food, so reason was design activities around food, he enjoyed food, he also needed to eat more didn’t he because he was losing weight?

LB: Yes

OL: So was the thinking if we design activities around food he’s going to be happy to participate in those activities, and get some joy out of those activities, because in general he likes food?

LB: Yeh it was, in general person centred and he also showed excitement around food

OL: Yes, the other bullet, red cup and yellow cup [missed question]

LB: They were his personal ones, because for his autism and dementia, that was helpful for him.

OL: Would you say he was attracted to those sorts of bright colours?

LB: Yes

OL: Could I ask you to turn to page 370 please. Am I correct in saying this is a part of the My Plan for Life document?

LB: Yeh

OL: And this is the eating and drinking part of the care plan, for Marcus?

LB: Uh hum

OL: And it was written on the 17 June 2022, was due to be reviewed the following year but of course unfortunately Marcus had died by then. We’ve got some other versions, older versions of this, each time there’s a new version of this plan, eating drinking plan, how was that communicated to you?

LB: Umm, I believe any relevant information was sent in an email to all in the Cheddar group email. And in the communications book.

OL: So were you aware of this version of Marcus’s eating and drinking plan from mid June 2022?

LB: I ccan’t remember looking at it, now, if it’s any different to the one before to be honest, it’s quite a long time since I’ve seen it.

OL: Yes, you’re saying there was a system in place by which you and other staff members were notified of an update to someone’s care plan?

LB: I believe that would be included in the updates, yeh

Oliver then took Laura Bolus to a bullet point in the document.

OL: The sixth ones says ‘I may try and pick up foods which do not comply with my guidelines if they’re left around’. And I think you’ve already said in your evidence, you were aware of that?

LB: Yes

OL: That’s why there’s a gate in the kitchen area, Marcus had to be supervised and so on?

LB: Yes

OL: The coroner has already taken you to this. It says ‘my support team must be vigilant and not leave unadapted food where I can access it’. Do you recall reading this care plan and reading the words unadapted and questioning what it meant? In the same way you’ve questioned what it meant in your answer to the coroner today?

LB: I can’t recall

OL: So I’m really clear what your evidence is, are you saying that you didn’t consider that uncooked rice was food? Or that you did consider that it was food not adapted for eating, it was food? At that time?

LB: At the time it was not food, it was not, I didn’t see it as a risk of food, that Marcus could try and access as food.

OL: You didn’t see it as a risk that he would eat it?

LB: No

OL: Could I ask you to turn to page 321, now this is a transcript of an interview between Eve Salthouse, the Brandon Trust Investigating Manager, and also a note taker Tracy O from human resources, and Mandy Hopkins, Locality Manager, there in a support role for you, and you, on the 7 October 2022?

LB: Yes

OL: Do you remember this interview?

LB: Yes

OL: This is the Friday, after the previous week when the incident had happened on the Wednesday [my paraphrase]. Were events fresh in your mind at the time of this interview?

LB: Definitely fresher

OL: Fresher than now?

LB: Yeh.

OL: If you turn over the page to 322, there’s some red writing in the first paragraph. Is the red writing, wording you added after the interview when it was sent to you for checking?

LB: Yes

OL: So sometime after 7 October, soon after that, they sent you a draft, then you were permitted, in fact asked to review it and correct anything you wanted. Is that right?

LB: Yes

OL: Can I ask you to turn to page 328 please. Going to start in the middle of the page, where you were asked about the rice, in a dish, you were asked about the dish ‘it was a white carton, like a pudding carton’… larger than a cereal bowl, smaller than [missed]

Sensory rice, is uncooked but dyed to make an attractive colour?

You say ‘yes, rice dyed to make it a bright colour, cider vinegar is used, you can leave out in the sun, can be cooked in oven so gets a hard texture, is grainy and has a sensory feel, not meant to be edible in any way. I obviously didn’t see the risk, but can understand him not understanding that’.

Couple of questions about that. You said the rice, you can leave it out in the sun and can be cooked in the oven to get hard texture. Rice used by you and residents on 28 September, had that been put out in the sun or baked in an oven?

LB: It was in the sun, on a window sill at my house

OL: Was the effect of, you’d dyed the uncooked rice with cider vinegar with food colouring is that right?

LB: Yes

OL: Afterwards you dry it in in the sun?

LB: Dry it out in a bag left on the windowsill, so it soaks up all the liquid and goes all hard, with a sensory feel, yeh

OL: Texture wise, was the end result of the sensory rice, the same as uncooked rice we’re all familiar with, before its cooked, or was it harder?

LB: It’s harder

OL: My next question is about your view of the risk. You say, you said, ‘I obviously couldn’t see the risk then, but I can understand him not understanding that’. Him means Marcus?

LB: Yes

OL: Were you saying in the interview then, you could understand then at time of the interview, he wouldn’t have had the capacity or ability to weigh the risk, to see it was a risk, is that what you said there?

LB: Yes

At this point Oliver suggested a break to the coroner. He said he still had further questions. The coroner warned Ms Bolus that she was under oath and couldn’t discuss her evidence with anyone, but she could step outside for some air if she wished.

Court was then adjourned for 15 minutes.

OL: We were looking at page xx, I had asked you about the last two lines of that page and I think you’d said at the time of this interview your view was you could see Marcus lacked the ability to understand the risk of leaving out rice and conkers, is that right?

LB: Uh, yeh

OL: But at the time, when you say I couldn’t see the risk then, does that mean at the time of the 28 September you didn’t realise that was a risk? It didn’t occur to you Marcus wouldn’t have the ability to view unattended rice and conkers as a risk? Is that right?

LB: Correct

OL: Can I just check with you one other thing in this interview, can I ask you to turn back to page 3?4 please, and slightly above the lower hole in the page, you’re asked, yes not leaving unadapted food when he could reach it and you say ‘I’m aware of the things we have in place in the kitchen where we have a lock on the cupboards and fridge where he can not access food’ and you say ‘I did not think it was necessary that he had to be supervised when eating’. Can I check that’s what you thought, you didn’t think he needed to be supervised when eating, or is that a typo?

LB: It’s not I thought personally against that, from my understanding I didn’t know he needed to be supervised when eating at all times. I know staff didn’t always supervise him when eating, but yeh.

OL: So is your evidence today… you didn’t realise his care plans required him to be supervised when eating?

LB: Yes

OL: Not that you disagreed with it. You didn’t realise he had to be supervised when eating?

LB: Yes

OL: How do you explain that with the evidence you’ve given in your statement and to the coroner today, that you’d read all the care plans that specify the risk around food, the choking risk, and the need for supervision? How is it possible you didn’t realise what was at the core of those plans?

LB: That was my understanding at the time, I believe it was from when food was given to Marcus in the home and other residents who needed more support, he was left unsupervised with food, that’s why my understanding was that was the case.

OL: You’d been on holiday supporting Marcus in August 2022

LB: Yes

OL: With his family?

LB: Yes

OL: During that holiday Marcus was always supervised when eating wasn’t he?

LB: Yes

OL: Was there ever a conversation with the family, when you were there for a week with them, about the possibility Marcus might be ok when eating if unsupervised?

LB: There wasn’t a conversation, no, around that. But he wouldn’t have been unsupervised on that trip, he was in an unfamiliar area and needed support with getting around the accommodation, whereas at the home he’d walk around to whatever room he wanted.

OL: No he didn’t have 1-1 staffing during his waking hours did he?

LB: No

OL: But when there was food he was always supervised wasn’t he?

LB: At the home?

OL: Yes

LB: I think there were times where he wasn’t, when he was on his own eating in the dining room or the kitchen.

OL: There were times when he was left by himself eating?

LB: Yes

OL: Is that something you personally saw happen, or you’re aware of through other means?

LB: Yeh, its stuff I saw. That’s why it was my understanding that it wasn’t at all times, to be supervised when he was eating.

OL: When you saw it, were you in the dining room assisting and supervising residents with their eating?

LB: Yes

OL: So he was supervised, because you were there supervising him eating with other residents?

LB: With other residents?

OL: I’m trying to understand your evidence, you say here you didn’t understand he needed to be supervised when eating, you say there were times he was left unsupervised eating. So how did you know that?

LB: Times when he’s been in the kitchen with another resident, and staff or myself have left the room to assist people in the other room who needed help with eating. There might have been times when there wasn’t someone watching.

OL: When you say might have been times, that’s a possibility?

LB: Yes

OL: Are you aware of times when Marcus was left without supervision when he was eating?

LB: I believe there was times, I’m remembering it, but just can’t remember who was involved, when it was or how long for.

OL: Right. On the 28 September 2022, can you help me with who was on duty, the nurses and the support workers. My understanding was you were on duty at that time, there was Sue Watts and Laura Chivers, who were Support Workers, is that right?

LB: Yes

OL: Then there were two nurses, [missed] and Shabeena Saleen. Is that right?

LB: Yes, Shabeena was the nurse on shift for that morning

OL: So there were two registered nurses and two support workers, plus you?

LB: Yes

OL: Were you acing in the role of Support Worker, so 3 support workers plus nurses, or were you acting on that day as Activities Co-ordinator?

LB: Umm, I cant remember, I think 2 support workers is quite stretched for 7 residents, so, I know earlier that week I supported another resident in hospital and was doing support worker duties, but I can’t recall that day

OL: And are three support workers, plus two nurses, is that the regular staffing contingent or is that under staffed?

LB: Umm, [long pause] I don’t, yeh, the two nurses and three support workers, um, yeh I think that’s pretty standard I’m not, I can’t remember to be honest, it’s been a while

OL: You said in your interview, this is at page 329, at the lower hole punch in the page, you were talking about when you went with Marcus in the ambulance to the hospital?

LB: Yeh

OL: I’ll just read it out so you can follow it with me, ‘when we were in the garden with Marcus and the ambulance was there, they said someone usually comes to the hospital, so I said you want me to go? Shabeena looked at me… I felt I should go, I was responsible, I felt sometimes panicked and put on me…. It had already been a stressful week, not to make excuses but if done things properly, looking back is all’.

Can I unpick that a little bit. You’re saying Shabeena, the nurse, looked at you as though you should go and you felt panicked, and they sometimes put things on you like that. So, were you reluctant to go to the hospital with Marcus?

LB: Umm, I was in a way that, was, you know, out of my comfort zone, um, and just yeh, but like obviously it wasn’t about me, it was to support Marcus in that situation. So yes, um, I wanted to support Marcus, but um, I just felt quite alone in the um, decision of that.

OL: Do you think it, was there a discussion about whether or not you should go, or maybe there was someone more appropriate among staff to accompany Marcus? Was there a discussion about that?

LB: No

OL: Do you think it would have been more appropriate for another staff member to go, rather than you?

LB: Yeh potentially

OL: Why is that?

LB: Umm, because looking back I don’t think I handled it well, with if I, could have maybe, had a bit of a calmer approach, I would have been able to like, work um, a bit better, I don’t know, I don’t know, it just

OL: It was clearly very distressing for you, and for everyone I imagine, is that right?

LB: Yes

OL: When you say you might have been calmer and handled it better, what could you have handled better?

LB: I mean I don’t know because I did just support Marcus in the hospital, that’s what he needed, someone to support him there. I’m just not familiar in those settings, I don’t know, the health needs, when Katherine came she said he should have had a learning disability representative, I didn’t know that, I could have had that support earlier on, if I needed to ask questions, what support maybe I should have asked for on the day from the hospital

OL: Support from the hospital about what, for whom?

LB: What do you mean?

OL: You could have asked for further support from the hospital? Support for you, or what?

LB: There was a lot of waiting around, for, I don’t know, what the next steps are, there was a lot of waiting around and I didn’t really know what questions to ask, I was just waiting for updates.

Oliver asked to turn his back and spoke with Marcus’s family, before informing the coroner he had no further questions. The coroner then moved to Mr Lindsay if he had any questions, he did.

SL: hope you can see and hear me, I ask questions on behalf of South West Ambulance Service, and the paramedics. Can I just clarify what you told the paramedics when they arrived please, by way of introduction. When you were part of the investigation carried out on 7 October, were you asked about that?

LB: Sorry

SL: Were you asked about what you told the paramedics?

LB: No I don’t recall that being in that part of the investigation

SL: Do you remember telling them anything about what you told the paramedics, the investigators that is?

LB: Umm, I think, did I explain that when the paramedics arrived I told them, but I can’t remember if it’s in this interview, sorry, can I just have a look

SL: Yes, of course

LB: No it doesn’t look like I had mentioned that in the investigation notes, no

SL: That’s ok, that’s Bundle 2 you’ve got there, could you look at page 317, you’ll see in the third paragraph, one of the findings the investigator made was none of the staff involved recall any mention of conkers being ingested. Do you remember if you told the paramedic Marcus might have eaten a conker?

LB: At the home? Yeh, yeh

SL: Do you remember if you told the paramedics that he might have eaten a conker?

LB: I would have mentioned the conkers was in the rice, not sure I would have said he might have eaten a conker.

SL: That was 7 October, that interview was taken, your statement written out a year later, sorry 10 months later. Did you mention there you told the paramedics he might have eaten a conker? If you don’t remember.

LB: I can’t remember, sorry

SL: Did you think at the time, he might have eaten a conker, at the time of the incident?

LB: It was a thought, that I did relay originally, because no one asked around the conkers, they were all interested in the rice, I thought that was ruled out as something that was a concern.

SL: Let me just pick that a part a little more. When you say at the time, when was that, what time are you referring to?

LB: When we got to the hospital

SL: Is that on arrival at the hospital, or when you saw Nurse Khorsand?

LB: When people were coming up to the bed we were asked

SL: So after Marcus was admitted to hospital?

LB: Yes

SL: Are you saying you were asked about what he might have eaten?

LB: Umm

SL: If you can’t remember, please do say so

LB: I can’t remember what was said

SL: But you remember the conversation with Nurse Khorsand as I understand it?

LB: Nurse? Katherine?

SL: Yes. Do you remember wondering about whether he might have eaten a conker?

LB: We spoke about that being a possibility, I remember that, it was later that day when Katherine arrived.

SL: I don’t need to take you to this, ma’am I’ll read through page 81 bundle 3 made in July, ‘we discussed the idea whether Marcus swallowed a conker, we thought unlikely to happen given Marcus had no teeth and was on a pureed diet’. Was that your view or the view of both of you?

LB: Both of us discussed, Katherine wasn’t there at the time so I ran through the day with her

SL: That discussion, is it right you had that discussion because you looked at the x-ray?

LB: I can’t remember if it was before or after the xray

SL: let me help you, we heard yesterday from Katherine the x-ray was visible and black circular object in his lower left abdomen, does that ring any bells?

LB: I do remember seeing an x-ray but don’t remember that part of it

SL: So when did you come to the opinion that he was unlikely to have swallowed a conker?

LB: It wasn’t necessarily my opinion

SL: You said in your statement, ‘we thought it unlikely that he would have swallowed a conker’, when did you first come to that view, do you remember?

LB: I always saw it as a possibility, I wasn’t in the room at the time, that was what was in the rice.

SL: Before then, did you think he had swallowed a conker?

LB: I thought it was unlikely

SL: Just one final question if I may, if you thought it was unlikely that he had swallowed a conker, it follows doesn’t it that it’s unlikely you would have told the paramedic that he likely swallowed a conker?

LB: That does make sense, but I did say it was part of the activity.

SL: Do you mean that there were conkers in the activity?

LB: Yes, yes

SL: Thank you, that’s all ma’am

It was then over to Rhys Hadden for University Hospitals Bristol and Weston.

C: Mr Hadden?

RH: Yes, thank you. Ms Bolus, hi, can you see me ok? I ask questions on behalf of the Trust responsible for BRI (Bristol Royal Infirmary) hospital. I’ll pick up with the question you’ve just been asked regarding information you shared with the paramedic. I’ll not take you to them, but there’s no mention of conkers in the ambulance notes. There’s no mention of conkers in the 999 call log. The only evidence we have is a statement from the paramedics, will read out what she says and see if that triggers your memory, for your reference ma’am it’s page xxx of the statement bundle. Statement from Sadie Hebden, one of the paramedics who attended at the time. ‘during this time she was simultaneously getting an account of events from staff… lady… said sensory rice, among this other items, I remember conkers being mentioned but staff felt was too big to be responsible for the choking incident’.

Is that your memory, mention of conkers but then also discounting it as a possibility of being ingested?

LB: I can’t remember exactly what I said but that could have made sense, yeh

RH: Is it likely as you thought it was unlikely he swallowed a conker, that was your view and it remained that. When did you find out in fact he had swallowed a conker?

LB: Not until much later on, like, after the investigation.

RH: Yeh, as late as perhaps when you were preparing your statement for the inquest? Or before then?

LB: I can’t remember, was a while after it, I didn’t know at all

RH: Thank you. If we can turn then to what happens on you arriving at the hospital. We know from notes the ambulance arrived at 12:18, there’s a handover at that point between paramedics, the ED doctor who was with a nurse, what were you doing during that handover? We know Marcus was sat on the floor for some periods, were you part of that discussion, were you part of that?

LB: I don’t remember being part of that, I know I was with Marcus but I don’t remember what was said.

RH: OK, your evidence today was you can’t actually remember what you said at hospital. That does differ from what you say in your statement that you prepared in June for the inquest… you said ‘I can’t remember exact detail, but answered questions when asked… believe I did mention conkers at some stage but can’t recall who I spoke to’…. It’s some time on, but is your evidence now you can’t remember what you said? Rather than you did mention conkers at some stage, but can’t remember who to?

LB: Yes, I can’t remember

RH: You said Marcus was seen by a number of different clinicians during your time there in hospital. Firstly, we heard from Katherine Khorsand yesterday that on handover with you, you left the hospital around 6 or 7 o’clock, does that accord with your memory?

LB: No, I thought it was more 9 or 10pm

RH: During the afternoon, Marcus had been seen as we now know by Dr Creech [sp?] and a nurse, in particular following his investigation, he requests that Marcus be seen by someone from ENT, that’s Dr Embury-Young, I would like to take you to her notes if I can, Volume xxx of the bundle, page 105.

Now, just before we get there, we have a statement also from Ms Embury-Young, she says that in her statement, I’ll read this, that will inform them, the notes. For your sake ma’am 170 of witness bundle, paragraph 5, says ‘I saw Mr Hanlin at 14:04, I can’t recall the assessment in detail… do recall meeting Mr Hanlin… took place in resuscitation bay of A&E… very agitated at time, not able remain on trolley… recall moved himself from sitting on the bed to the floor, remained agitated, requiring assistance from his carer, a nurse and myself’… Is that accurate of how Marcus was presenting and what you were doing?

LB: Yes

RH: She then says this, ‘I recall getting collateral history from carer who attended A&E with Mr Hanlin… my clinical history therefore relied on the information the carer was able to give me’

LB: Uh hum

RH: If we return to the notes, the history here is everything she obtained from you Ms Bolus, of how he came to be in hospital, now, unlikely you’ve seen these notes before, do you need a chance just to read them?

LB: Its ok I’ve had a look

RH: There’s no reference to a conker being mentioned, even as part of the sensory activity, the focus is very much on sensory rice… some explanation of what that was… says in middle of the page not witnessed but heard choking from carers, rice coming from mouth and nose, therefore assumed… so from these notes more likely than not you didn’t mention conkers at all to Ms Embury-Young?

LB: I may not have

RH: May I just turn my back? No further questions.

It was then Mr Brownhill’s turn to ask questions of Laura Bolus. He is the counsel for Brandon Trust.

IB: Ms Bolus I’ll ask you questions first about the conkers, then about sensory rice, promise won’t ask lots of questions already asked. Want to be very clear about your evidence, in respect of what you told paramedics when they attended. Is it right you told them you’d been doing a sensory activity?

LB: Yes

IB: Is it right you told them that sensory activity involved rice and conkers?

LB: Yes

IB: Is it right you told them you weren’t in the room when Marcus ingested that activity?

LB: Yes

IB: Is it right you told them Marcus was choking in some respect?

LB: I don’t recall he was choking

IB: What was it you described to them?

LB: He was like spitting bits of rice out

IB: Yeh, so when it came to what was described to the paramedics, you told them was sensory activity, what it involved, you told them you weren’t there and you told them thereafter was then some difficulty with Marcus, and you told them what he was spitting out was rice. Is that correct?

LB: Yes

IB: Did you, at any stage, say he was specifically choking on the rice?

LB: I’ve forgotten the term for it but we thought he might have inhaled it

IB: Aspirated it?

LB: Yes

IB: Your background, completely unmedical, you were simply telling the paramedics what you’d seen weren’t you?

LB: Yes

IB: Alright. Can we move then to your activities and your job as Activities Co-ordinator

LB: Yes

IB: Is it fair to say you were fairly enthusiastic about your role as Activities Co-ordinator?

LB: Yes

IB: And you were keen to give residents at the home things to do?

LB: Yes

IB: Also you were being creative in that respect?

LB: Yes

IB: You were told by those managing you at the home there was a risk about Marcus and food, is that correct?

LB: Yes

IB: And you‘d read the SALT Guidelines, is that right?

LB: Yes

IB: And I think a day into being on the job you’d read various care plans for various people is that correct?

LB: Yes, there is a lot to read through

IB: Exactly, in fact if you‘ve got bundle 2 in front of you I’ll take you to one of the pages, I think is written outline of one of your first supervisions, p404 please … this is a print out of your supervisions at the Brandon Trust, do you recognise it?

LB: I recognise it’s the online system

IB: Bottom of page, date of supervision, says you’ve spent the first month getting to know everyone and reading folders so getting to know [missed]

LB: Yes

IB: Next page over said started Cheddar Grove Induction Sheet, what Mr Lewis took you to earlier, food hygiene training completed and you’d read the SALT guidance, is that correct as well?

LB: Yes

IB: So, in respect of working with Marcus, you knew food motivated him, you knew there was a risk, and you knew safety measures had been implemented around the home in respect of Marcus and food?

LB: Yes

IB: The previous activity with shells, you’re not suggesting that was still out in the home at the time of the incident were you?

LB: To my memory it would have been

IB: We heard yesterday Katherine had found a brightly coloured object and she’d moved it

LB: Things do get moved, are we on about the yellow rice?

IB: Yes

LB: That was the beach one.

IB: Her evidence was she’d moved it out the way, out of reach of residents.

LB: What recently?

IB: Before the incident

LB: Things did get moved

IB: It wasn’t something you were using every day, you weren’t tracking things within the home?

LB: No

IB: This activity, is fair to say you were doing something, it wasn’t an activity directed at Marcus was it?

LB: No

IB: Is it fair to say you didn’t expect Marcus to engage with this activity?

LB: Yes

IB: So was it you were being enthusiastic about getting an activity for another resident in the home?

[Missed answer]

IB: Right, so in terms of you leaving the room, that I think was to go and provide another activity in a sense? You’re going to make sure hats, gloves, scarf so another activity could take place?

LB: Yeh

IB: In terms, finally, of Marcus and eating, you said might have been times when he was unsupervised eating, are you able to give an example of that at all?

Long pause

IB: The only reason I ask that is you weren’t day to day feeding Marcus were you? Because you were the activity supervisor.

LB: No but I would help with food in the evenings, and help residents with food when needed, and lunch as well.

IB: But would you accept that wasn’t your principal focus?

LB: Yes

IB: Thank you ma’am, those are my questions

Then it was over to her own legal counsel, Anthony Collins, to ask her questions.

AC: Ms Bolus, turning you back if I may to a question you were asked in relation to page 3?? of bundle two, its notes of the incident investigation… its final entry on that page, where it says LB ‘yes so essentially is rice dyed to make it bright colour…. So gets hard texture so its grainy, has sensory feel, but it’s not meant to be edible in any way, I obviously couldn’t see the risk then, but I could understand him not understanding that’… final line, is that a comment you now make with hindsight having experienced what has now taken place?

LB: Yes

AC: Thank you. And you were asked about your engagement at the hospital and how you would have handled things, could have handled things a little better, and the point about a learning support nurse, would you have thought if there was a learning support nurse, they would have been offered

Counsel interjects… [can’t hear]

AC: My note a learning support nurse was mentioned. [can’t hear] OK, it’s not a particularly big deal. I’ll move on.

RH: Sorry ma’am, my recollection was reference to a learning support nurse was not something the witness mentioned.

C: Maybe we ask the witness what she requested and what she thought should be available?

AC: It’s not a big point ma’am I’m happy to move on. Your role at Cheddar Grove then, you had a joint role as Activity Co-ordinator and Support Worker

LB: Yes

AC: You initially started work with Brandon Trust on a part time basis on 13 September 2021, and move to working full time with them in June 2022, so around 3 months before the incident took place?

LB: Yeh

AC: Would it be fair to say when you took on that dual role you had a little loss of confidence. Is that fair to say?

LB: Yes

AC: And you asked for clarification of what the role entailed?

LB: Yes I wasn’t going into a dual role of Activity Co-ordinator and Support Worker, was full time as Activity Co-ordinator, but would still be doing support worker role.

AC: If we go to page 322

Coroner checks page number

AC: You discuss with Mr Pullen the role, you provide a summary of the job role discussed with Mr Pullen, is that the extent of the role you discussed with Mr Pullen?

LB: Yes

AC: So when you went to see what residents had, hats, gloves on the day of 28 September, you thought that was one of the responsibilities that was part of your role, is that correct?

LB: Yes and Marcus in particular didn’t have a key worker at the time, and I was supporting Marcus on an activity, when it was starting to get cold in September. … just wanted to make sure everyone had appropriate, yeh, winter wear. As I’m quite proactive, but it’s all on us, duty of care to look after everyone there in that setting, especially if I’m supporting someone out in the community, I didn’t feel if they didn’t have hats and gloves and anything, it’s not really looking after them is it

AC: Thank you. Turning to the activity yourself you’d conducted sensory activities with residents before the 28 September hadn’t you?

Laura Bolus asks him to repeat the question, he does.

LB: Yes

AC: And whilst they weren’t all exactly the same activities, was it fair to say they were broadly the same?

LB: Similar yes, sensory dish with shells, then potato stamps in paint, making patterns, play dough, made play dough and yeh, just some examples of previous ones.

AC: Thank you. I won’t take you back over the incident yourself you’ve been asked a number of questions about that, when you come back into the room after you’d left to look for the hats and coats, you see Marcus and notice the rice and conkers aren’t where they used to be, you initially speak to Sue Watts, is that correct?

LB: Yes

AC: Then within a short amount of time you talk to Shabeena, the nurse on duty?

LB: Yes

AC: Can you give us an indication of how soon after entering the room you spoke to Shabeena?

LB: I can’t remember if I got Shabeena, or Sue got Shabeena, just remember Shabeena being involved pretty quickly…

AC: Bundle 3 then, page 80, might just assist you


AC: Paragraph 30 of your witness statement, final sentence, ‘I also spoke to Shabeena (the nurse on duty) and made her aware of this, what might have happened’. So, do you remember speaking to Shabeena?

LB: Yes

AC: Can you give us any indication of how soon after re-entering the room you went to speak to Shabeena? 1 minute, 5 minutes, 10 minutes, a rough indication?

LB: Couple minutes, yeh, I can’t remember

AC: So within a couple minutes the nurse on duty is notified of the incident, is that fair?

LB: Yes

AC: Thank you, nothing further.

The coroner said that she had a point of clarification, and then there was one further clarification question from Oliver Lewis.

C: Just one point of clarification I wanted to come back on, when you spoke to the nurse in charge, Shabeena, did you tell her about the sensory activity you were doing?

LB: Yes

C: Did you tell her that it involved rice and conkers?

LB: Yes

C: the same point, when you spoke to Sue, did you tell Sue that the sensory activity involved rice and conkers?

LB: Yes

C: So the three of you were all aware that the activity Marcus had interacted with before he was found was a bowl that contained rice and conkers?

LB: Yes

C: So when the paramedics arrived, were Shabeena and Sue present?

LB: Yes, Shabeena definitely was, maybe Sue wasn’t when the paramedics came, I can’t remember but Shabeena definitely was.

C: OK that was it, thank you. Does anyone else want to come back on this witness, just conscious do want to release her, she’s been in the box a long period of time…

OL: Just one point of clarification, family reminded me of course on that day, Sophie de Beaufort Chappell was upstairs, she says in her statement she wasn’t working on shift but was doing manual handling training. So can I just ask about staffing contingency and whether it was regular on that day, or whether understaffed? Was one nurse on duty, Shabeena, and Sue and Laura Chivers and you, is that correct?

LB: Yes

OL: In your view is that set up, 1 nurse plus 3 Support Workers that would include you, is that normal staffing level or is that understaffed on that day?

LB: From my memory one nurse on shift was fine, um, but there would be a crossover in the day between the other nurse coming in, but to my memory Sophie wasn’t counted as the staff that day

OL: That’s right

LB: Shabeena was the one nurse

OL: Yes, was it staffed appropriately to have the one plus three non-trained staff, three support workers? Or should there have been more?

LB: That was normal

OL: Alright, thank you very much

The coroner checked no one had any further questions for the witness, they didn’t, and she was released just before 1pm.

Court then adjourned for lunch.

[Unfortunately am I am unable to report from Marcus’s inquest for the rest of this week as I am reporting from Beaconsfield for the final two days of Fern Foster’s inquest. I will try to return to Bristol for Marcus’s conclusion. With thanks to all those who are reading, sharing, supporting and funding my reporting, I couldn’t do it without you. Thank you].

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