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The Death Of Marcus Hanlin, A Man With Down’s Syndrome Who Lived At Cheddar Grove Nursing Home, Was Contributed To By Neglect

Marcus Hanlin died on 2 October 2022, aged 57-years-old, after inhaling uncooked rice and swallowing two conkers at Cheddar Grove Nursing Home, Bristol. The incident occurred when Marcus was left unsupervised, contrary to his support plan that recorded that Marcus required supervision around food at all times. Cheddar Grove Nursing Home is operated by the Brandon Trust and is rated by the Care Quality Commission as ‘requires improvement’.

Marcus had Down’s syndrome, severe learning disabilities, autism, and Alzheimer’s disease. He did not use words to communicate, lit up the room with his smile and loved seeing his family. Marcus had dysphagia (swallowing difficulties) and was assessed as being at risk of choking, so was on a pureed diet. Marcus’ support plan directed staff to be vigilant around food, as he “will help [himself] to food or drink if it is left around”.

On 28 September 2022, a support worker who knew about Marcus’ choking risk, left him alone in the dining room of the care home where Marcus had access to a bowl of uncooked, hardened rice and conkers that had been a ‘sensory activity’ for another resident. Marcus swallowed two conkers and inhaled the rice. As a result, he developed aspiration pneumonia, which sadly caused his death at the Bristol Royal Infirmary on 2 October 2022.

During the inquest, the Coroner heard evidence that:

  • The registered manager had been in post seven months, had no training as a nurse, and did not know what was in the residents’ care plans.
  • The nurse in charge that morning was unaware that the support worker was using rice or conkers, and didn’t know she left Marcus alone with those items.
  • None of the other staff members knew that the support worker had invented ‘a sensory activity’ with items dangerous to Marcus, and had they known about it, they would have stopped it, given the choking risk.
  • The staff at Bristol Royal Infirmary were not informed of the possibility that Marcus had swallowed conkers, which affected their assessment of the incident.

After Marcus’ death, the Brandon Trust made extensive changes to their policies and practices regarding swallowing difficulties and choking prevention, particularly with respect to supervision, communication, staff training and audit.

The Coroner concluded that Marcus’ death was an accident contributed to by neglect, on the basis that being left unattended was a very serious failure to provide care.

Marcus’ family said: “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.”

Susie Labinjoh, Partner and solicitor at Hodge Jones & Allen, said: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.”

Jodie Anderson, senior caseworker at INQUEST, said:

“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.”


For further information or request for comment, please contact Susie Labinjoh of Hodge Jones & Allen Solicitors at

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

Journalists should refer to the Samaritans guidance for reporting on inquests.

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