Part 3

The deceased was Marcus Jon Hanlin. He died on 2 October 2022 at Bristol Royal Infirmary.

Marcus was cared for in a nursing home. He suffered with Down Syndrome and had dysphagia.

There was a care plan and guidance in place for staff to follow to keep him safe.

On 28 September 2022 Marcus attempted to swallow uncooked rice and two conkers whilst left unattended.

This should not have happened.

One conker became lodged in his oesophagus and he inhaled the rice grains which caused him to suffer aspiration pneumonia.

He was admitted to hospital on 28 September 2022… despite receiving treatment for aspiration pneumonia this caused his death

Conclusion

Do not find this failure to be simple… find was gross failure, failure to follow care plan and SALT guidance, and to leave unadapted food where Marcus could access it.

This gross failure caused his death.

Accident contributed to by neglect.

[I’ll write up the coroner’s summary later tonight when I get home]