Marcus Hanlin Inquest – Coroner’s Summing Up

The Senior Coroner for Avon, Maria Voisin, returned to court this afternoon, on Day 6 of Marcus Hanlin’s inquest, to give her summing up and conclusion.

She said that she was aware that people would be trying to take a note and that she would try and go slowly [even with this I still could not catch all she said to the degree that I’m confident of it. Just a reminder my posts and reporting are not transcripts, but they’re as accurate an account as I am able to share, based on what was said in court].

In court were the interested persons, their legal teams, a number of members of the press, some of the support workers from the home Marcus lived in, and some more senior staff from Brandon Trust. Attending remotely were press and some of the doctors who had treated Marcus.

The coroner started by reminding those in court that “this inquest, like all others is an enquiry, it is not a trial” and she went on to expand that it is a “fact finding investigation to find out how a person died, it is not a method of apportioning blame”.

She explained the rules that she worked under and that her job was to ascertain:

  1. Who the deceased was
  2. How, when and where he came by his death
  3. Particulars for registering his death.

She said that the ‘how’ was to include the purpose of ascertaining ‘in what circumstances’. She told the court that on Friday she had not received any submissions that this should be an Article 2 case, where the conclusion should be widened.

She said that it was important that her conclusions were not expressed in a way that could be used to determine any matters of criminal or civil liability.

She confirmed Marcus Jon Hanlin was born in July 1965 [I’ve withheld the exact date] in Birmingham. She said his usual address was a “Brandon Trust service”, based at the old St Oswald’s Vicarage, 26 Cheddar Grove, Bedminster.

She said that Marcus’s occupation should be recorded “simply as dash, dash, dash”.

The coroner told the court that she needed to consider how Marcus had died.

She said that she wanted to say at the outset that she was very grateful to the witnesses, the family, and the interested persons for “providing me with information to assist me in my enquiry”.

She said that the first person she had heard evidence from was Anna Rose, Marcus’s mother, who she said had bravely read her statement in court. She highlighted some of what it told us, including that Marcus used non-verbal communication to communicate his likes and dislikes, and some of what he was like.

The coroner said that Marcus had Downs Syndrome and was diagnosed “later in life” with obsessive compulsive disorder and autism spectrum disorder “and more recently” with early onset Alzheimers with associated seizures. She said that Marcus had cataracts and a swallowing problem and “as a consequence” was on a pureed diet.

He [Marcus] needed supervised whenever food was involved, and anything he could construe as food, was in his reach.

The coroner said that she had heard evidence that Marcus had moved to Cheddar Grove on 1 February 2021. She said she had heard evidence from his GP, Dr Mutch, about his health and the way that decisions were made in his best interest.

She said that Dr Mutch had confirmed that Marcus had a swallowing difficulty and that as a consequence he was at risk of aspiration of food into his airway. He had been assessed by the SALT [Speech and Language Therapy Team] Team in February 2021. They had recommended that Marcus be placed on a Level 4 Dysphagia Diet which “consists mostly of pureed food and thickened drinks… given little and often” and that staff needed to be careful not to overload Marcus’s spoon.

The coroner said that this diet was designed to minimise the risk of food going into Marcus’s airways. She said that Dr Mutch gave evidence that in September 2022 Marcus had a test to evaluate his swallowing difficulties and risk of aspiration, and that shen she had seen Marcus on 6 September 2022 she had recorded in the notes “no recent incidents of difficulty swallowing or choking”.

The coroner said that Marcus had a ‘My plan for life’ the Brandon Trust name for a support plan and risk assessment dated 17 June 2022. She said that the eating and drinking section noted Marcus’s risks as:

“choking, aspiration and death”.

That document, she said, indicated how to support Marcus.

She said that there were a set of SALT Eating and Drinking Guidelines that “must be adhered to at all times”. These are written as though from Marcus’s perspective and included:

“I may try to pick up food that doesn’t comply with guidelines if left around… my support team must be vigilant and not use unadapted food where I can access it”.

The coroner said that she had heard evidence from Keaton Pullen, the Registered Manager of Cheddar Grove, at the time. She said he had confirmed the My Plan for Life and SALT assessments.

Mr Pullen told the court, she said, that “uncooked rice is unadapted food” and that it “should not be left where Marcus could access it”. He said all staff had Dysphagia Training and First Aid training. The coroner said he had also said that “All staff had to sign and say they understood it”, it being the SALT Plan.

The coroner said that Eve Salthouse [the Brandon Trust Compliance Coordinator who conducted their internal investigation] confirmed that the SALT Plan included, in capital letters, the instruction:


The coroner said that the Registered Manager Keaton Pullen had also explained to her the staff training records, and the Induction Passport for Laura Bolus, a support worker with niche responsibilities as Activities Coordinator.

The coroner said that on the page for Marcus she had confirmed that she had seen “the support plans, risks assessments and Eating and Drinking plans”.

She herself had noted on the document, be careful with food and activities

The coroner said Mr Pullen had also been taken to the HR Dashboard. She said he confirmed that it was Laura Bolus’s responsibility to read the support plans.

The coroner said Laura Bolus had told the court that she knew Marcus well.

She had supported him at home and in the community. She had been on holiday with him in August 2022.

Laura Bolus confirmed that she had received First Aid training, and that she knew Marcus was on a pureed diet. The coroner noted that Laura Bolus had added that this was also because Marcus didn’t have any teeth and his vision was not great.

The coroner said part of her role was Activities Co-ordinator, and on 28 September 2022, she had set up an activity for other residents. This activity, the coroner said, was a “bowl with dried and dyed rice with conkers in it”.

Laura Bolus told the court, the coroner said, that “at the time she did not see this as unadapted food”. She did not think there was a risk Marcus would eat it, but she said she understood Marcus was not understanding of that risk. She said that she was aware that Marcus may try to “pick up food which did not comply with his guidelines”.

The coroner said that the activity took place in the dining room, on the table.

The idea was to use a spoon to fish the conkers out of the rice. Marcus was watching.

The coroner said “at some point Laura Bolus left the area” to check another resident had winter clothes for an activity.

When she returned she noticed the conker dish had moved … rice and conkers on the floor.

Marcus, the coroner said, was sat on the floor of the hallway. She described Marcus as “spitting bits of rice out”.

The coroner said she heard evidence from another support worker, Sue Watts. Said told the court that she had known Marcus from the time he arrived and she was aware of his swallowing guidelines.

When she was told by Laura Bolus that Marcus may have eaten some rice, she told the court she gave him a small amount lemonade. The coroner said that she “heard a pop sound and he brought up rice all over the floor”.

Sue Watts took Marcus to the bathroom to clean up, and he “seemed ok”. Her evidence was that he didn’t look like he was choking, he sat on the floor which was “normal for him”.

The coroner said she had evidence from Sophie de Beaufort Chappell, that she was leaving to catch a train at 11:15 that day. Shabeena Saleen, was the nurse on duty that day, and Sophie said she “came into the office shortly after 10am saying she was not sure if Marcus had eaten rice”. Sophie described Shabeena as calm and she told the court, as a consequence she didn’t consider that it was an emergency.

She checked on Marcus before she left and there was no obvious sign of discolouration [something else I missed, apologies], but he “did appear a little restless”. She said to Shabeena to call 111.

The coroner said that Sue Watt’s evidence was that Marcus was wobbling when walking so she got a wheelchair for him, before then noticing his lips were turning blue. Shabeena called 999.

The evidence of Laura Bolus was that she told Sue Watts and Shabeena Saleen that the activity involved rice and conkers. Both said in evidence they were not told.

The coroner said that Marcus was then taken into the garden for fresh air, and that’s where he was when the ambulance crew arrived at 12:18.

The paramedic, Sadie Hebden, said that she saw Marcus was in the garden in a wheelchair. She described him as “blue” and “agitated” with “short shallow breaths”. She told the court that she gave 5 hard backslaps to Marcus “nothing came out, but his breathing changed, it got more noisy”. She considered that he had a partial airway obstruction and would need to be taken to hospital.

Laura Bolus told her in the ambulance that the sensory activity contained “uncooked rice and conkers in a bowl”. She said that she considered if Marcus had swallowed a conker but his presentation would not fit that picture. The paramedic said that Laura Bolus told her “the conker was too big and Marcus would not swallow it”.

The coroner continued, saying Marcus was initially seen in the Emergency Department at the Bristol Royal Infirmary where he was assessed by Dr Cretch at 12:30. They considered Marcus had “a new, acute aspiration”.

He was then seen by Dr Embury-Young from Ear, Nose and Throat, who assessed Marcus at 14:04. She “obtained a history from his carer” [Laura Bolus].

Laura Bolus said she may not have mentioned conkers when providing a history to Dr Embury-Young.

Dr Embury-Young considered that there was “no laryngeal compromise” and the clinical impression was “aspiration of rice of an unknown quantity”.

The coroner said Katherine Khorsand arrived 4 or 5 hours after Marcus had been admitted to hospital. Laura Bolus was still with him. She helped with Marcus having an x-ray and when they were put up to view saw a dark circular ball area on the x-ray.

Laura Bolus said ‘Do you think that is a conker?’ Laura’s view was she didn’t know if he’d eaten a conker and this was unlikely.

Dr Reed explained to the court that Marcus had developed aspiration pneumonia, and on 30 September 2022 Marcus was moved to the respiratory ward.

The coroner said that two of the doctors giving evidence [Dr Reed was one, didn’t catch the other’s name, apologies] explained that Marcus was treated and cared for “but sadly his condition continued to deteriorate and he died”.

It is clear to me based on the evidence that the hospital were not made aware of the possibility that Marcus could have swallowed conkers until after Marcus had died.

The coroner said that Eve Salthouse carried out an investigation for Brandon Trust after Marcus died.

It concluded that Laura Bolus was helping others with an activity. Laura Bolus knew the risks. She left Marcus with a bowl of rice and conkers. She left him of her own accord and Marcus should not have been left.

The coroner then moved to the evidence of the expert, Mr Lordan, whose evidence had been read onto the record. His evidence was that:

Swallowing problems can occur 6 times more commonly in adults with Down Syndrome, compared to the general population. Furthermore, adults with Down Syndrome have a higher risk of aspiration.

With regards to the x-ray, he said that it was “not reasonable to expect a doctor other than a trained radiologist to consider subtle signs of an obstructing foreign body”, especially one that was opaque [the conker].

His opinion was Marcus received excellent hospital care over all.

The coroner then moved to the evidence of Dr Sheffield, the pathologist. At post mortem it was discovered that there was a “conker partially obstructing the oesophagus and another in his stomach … in addition to rice in his lungs”.

The coroner said that the expert found that Dr Clarke and Dr Buckley, who were treating Marcus at the time he was in hospital, were not aware of the conkers until his post mortem was conducted.

The coroner said that the main medical cause of Marcus’s death is:

Aspiration pneumonia due to aspiration of rice into his lungs

Part 2 Medical Cause of Death

1a) Aspiration pneumonia

1b) aspiration of rice into the lungs

1c) oropharyngeal dysphagia

2) oesophageal obstruction due to ingested conker and Down Syndrome

The coroner said she then needed to consider two possible options, whether Marcus’s death could be concluded as an accident with or without neglect, or a narrative verdict with or without neglect.

The coroner explained what each of these conclusions meant. She then said that accident could be found:

His death being the unintended consequence of him being left alone unintended.

She said that she would need to consider if that reflected the evidence of how he died. Next she said she had considered a narrative conclusion. She explained what that meant, a short statement summarising the factual conclusion of the circumstances, no opinion or judgement. She said that must not include findings where there were no direct causal link to the death, and that any acts or omissions must on the balance of probability, more likely than not, materially contributed to the death.

She concluded that a narrative could also be appropriate.

The coroner then said she had also considered the additional wording of neglect.

I must find from evidence that it is probable the deceased was someone in a dependent position because of illness or incarceration, that could not provide for himself and there was gross failure … substantial not just trivial … and that caused or significantly contributed to the death.

The coroner said that a gross failure is plainly more than a simple error.

The conduct must have caused the death … more than minimally, negligibly or trivially contributed to the death. It need not be the sole or principle cause of death.

The coroner said she had to decide whether there was a clear and direct causal connection between the gross failure and the death and whether there was an opportunity to provide care that could have prevented the death. She said she also had to consider whether the condition was known, or should have been known … was such to know action was necessary … such that action not taken was a gross failure.

The coroner said that she had heard the evidence and in applying the test, Marcus was clearly in a dependent position. He was cared for in a nursing home, due to his known needs.

There was a clear failure to provide the care Marcus required.

His care needs and risks were clearly set out in his Plan for Life Support Plan and Risk Assessment document, together with his SALT Assessment.

Staff were aware of the plan to care for him, to keep Marcus safe.

That plan, the coroner said, said that staff should not leave unadapted food where Marcus could access it. It also warned that Marcus would try and pick up food.

Uncooked rice is an unadapted food. It should not have been left where Marcus could access it.

The coroner said the support workers “should have realised the risk of leaving unadapted food where he could access it”.

The care plan relating to non adapted food was not adhered to.

Marcus was left with it on 28 September, and he did pick it up.

I need to consider if that failure was a gross failure.

The coroner said that the final part related to causation.

I do find Marcus consuming uncooked rice led to him developing aspiration pneumonia, which caused his death.

The coroner said that based on the evidence she heard she would make the following conclusion [reported earlier here, but also repeated below for completeness].

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


I 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.

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