Marcus was a very dearly loved family member and loving man. Ineffective management at Brandon Trust meant that care was not provided as it should have been, and as a result, he lost his life. His death was completely avoidable. While we acknowledge the necessary changes by the Brandon Trust following Marcus’ death, we only wish that robust management had been in place before this incident, and Marcus would still be alive today.

Additional comments from:

The family’s solicitor, Susie Labinjoh, Partner and solicitor at Hodge, Jones & Allen:

Respiratory disease, particularly aspiration pneumonia, is one of the biggest causes of death for people with a learning disability in England. Many of these deaths, like Marcus’, are totally avoidable. Marcus was an exceptionally vulnerable person who had a multitude of care and support needs. Despite the known risks to Marcus, he was left unsupervised with food which resulted in his avoidable death. It is the family’s view that poor management, post-training follow- up and supervision [and training] of staff contributed to this tragic incident. The family welcome the changes that the Brandon Trust have made since Marcus’ death, but it was sadly too late for him. The Coroner’s finding that Marcus’ death was contributed to by neglect rightly reflects how badly Marcus was let down.

Their Inquest caseworker, Jodie Anderson:

To thrive Marcus needed to be cared for by people who were good observers. Sadly, that wasn’t the case and a lack of vigilance ultimately cost him his life. Whilst the inquest process exposed the individual actions of one member of staff, it failed to scrutinise the culture and wider mismanagement of an organisation tasked with caring for some of the more vulnerable members of society. The 18 preventable deaths of people with a learning disability or autism in a care setting by choking since 2015 speaks to a national scandal reflecting the crumbling state of health and social care. Without proper oversight mechanisms, organisations will continue to ignore life saving recommendations made by Coroners and we will see the number 18 continue to rise.

The family is represented by Susie Labinjoh and Sion Morgan of Hodge, Jones & Allen Solicitors and Dr Oliver Lewis of Doughty Street Chambers.