Marcus Hanlin Inquest – Conclusion

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 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 […]

Marcus Hanlin Inquest – Jack Anderson

The first witness on Day 2 of Marcus Hanlin’s inquest was Jack Anderson who was called shortly after 10am. He gave an affirmation and confirmed his name for the record. C: What was your role at the time there? JA: I was the administrator at Cheddar Grove C: Right, thank you. How long had you […]

Marcus Hanlin Inquest, Keaton Pullen, Registered Manager Cheddar Grove

The final witness who gave evidence on Day One of Marcus’s inquest was the Registered Manager of Brandon Trust Cheddar Grove, Keaton Pullen. The CQC (Care Quality Commission, the health and social care regulator) state the following is the role of a registered manager: Registered managers make sure that people who use services have their needs […]

Marcus Hanlin Inquest – Katherine Khorsand

Katherine Khorsand gave her evidence shortly after midday on Day 1 of Marcus’s inquest. She told the court that she works for Dean Healthcare as an agency nurse. Asked by the coroner how well she knew Marcus she responded “quite well”. KK: I knew Marcus quite well, close to 2 years [can’t hear] he got […]

Marcus Hanlin’s inquest – Nick Stevenson, Bristol City Council

After a mid morning break on Day 1 of Marcus’s inquest, Nick Stevenson was called to the stand. He gave an oath and confirmed his full name for the court’s record. He told the court that he was a qualified social worker and he was registered with Social Work England. “Unfortunately, I did not know […]

Marcus Hanlin’s inquest – Anna Rose

The coroner had earlier checked that Anna wished to read her statement to the court herself. She gave an affirmation and told the court that she was Marcus’s mother, and a retired teacher, lecturer and psychotherapist. She said that Marcus was a “beloved son” and a “beloved brother”. “He meant something very special to his […]

Marcus Hanlin Inquest – opening and GP’s evidence

Avon Coroner’s Court is situated next door to the old long stay institution in Bristol, Farleigh Hospital (now a local enterprise park, belying its history as one of the hospitals where an abuse scandal in the 70s led to the ultimate move to close long stay institutions). Court 1 has cream walls and a public […]

Preventing Future Deaths: Claire Twinn, Mark McKessy and Shane West

Continuing with the exploration of Prevention of Future Death reports issued in 2023 for learning disabled and/or autistic people, today I cover three more reports relating to learning disabled people. You can find the first post here and the second here. Claire Twinn Claire was 47 when she died in December 2022. She had Downs […]

Preventing Future Deaths: Owen Garnett, Steven Duquemin and Matthew Dale

This is my second post about Prevention of Future Death reports published in 2023 relating to learning disabled and autistic people. You can read the first one, which includes an explanation of what PFDs are here. In this post I’ll cover the PFDs issued following the deaths of Owen Garnett, Steven Duquemin and Matthew Dale […]