Marcus was 57 when he died in October 2022. Marcus was charismatic, mischievous and always ready with a smile or a gleeful chuckle. He did not use words to communicate, and had Downs Syndrome, OCD, autism and in his later years Alzheimers. Marcus enjoyed swimming, or floating, cycling, craft, drama and music sessions. He loved to spend time outside and in the garden.

Marcus had three stints in long stay institutions in his life, the first as a child, then as an adolescent and finally at Farleigh Hospital, Bristol as a young adult. When he was 24, in 1989, Marcus moved with three people from his ward, into a house in the community. In the mid 90s Brandon Trust took over the management of that house, and were Marcus’s care provider until his death, a period of almost 30 years.

In late September 2022 Marcus was left alone in a room, where a sensory activity involving dyed rice and conkers was on a table in front of him. Marcus’s SALT plan said that he should always be supervised around food (and unadapted food) due to a risk of choking.

Marcus’s inquest has looked at how he was left with the bowl of rice and conkers and what happened next. Marcus swallowed two conkers and consumed some of the rice. He was taken to Bristol Royal Infirmary where he died some days later.

The coroner concluded that Marcus’s death was an accident contributed to by neglect

“I find was gross failure, failure to follow care plan and SALT guidelines and to leave unadapted food where Marcus could access it. This gross failure caused his death. Accident contributed to by neglect”