A man with Down’s syndrome, severe learning disabilities and poor eyesight, who died after swallowing conkers hidden in rice as part of a sensory activity at a nursing home, had been left unsupervised though staff knew he was fascinated by food, an inquest has heard.
Marcus Hanlin, 57, was on a regime at Cheddar Grove nursing home in Bristol that included him only eating pureed meals and being kept away from food preparation areas because of a risk of choking and swallowing issues.
But Hanlin was left alone in the dining room of the home with a bowl of coloured rice in which conkers were hidden that had been prepared as an activity for other residents. He swallowed some rice and two conkers, leading to him choking.
The inquest in Flax Bourton, near Bristol, heard that a paramedic who was called to the home was not told at first that conkers had been secreted in the rice. However, when she learned this, she discounted them as the possible cause of choking and did not pass the information on to hospital staff. The presence of one conker in his oesophagus and another in his stomach was found only after his death.
The inquest was told that Hanlin moved into Cheddar Grove, which is run by a charity called the Brandon Trust, in February 2021.
His food was pureed to lessen the risk of choking and a gate was installed in the kitchen to prevent him getting to places where solid food was being prepared. His care plan included the note: “My support team must be vigilant and not leave unadapted food where I can access it” and highlighted that he would try to help himself to food and drink if not stopped.
Eve Salthouse, the compliance coordinator for the Brandon Trust, said on the day of the incident, 28 September 2022, Laura Bolus, a support worker and activity coordinator, had organised the sensory activity involving the rice and conkers.
In the conclusion of her investigation into the tragedy, Salthouse said: “Laura Bolus was supporting other people with the activity. Marcus was watching.” She said Bolus was aware of the issues Hanlin had around food, adding: “She left Marcus unattended with a bowl of rice and conkers.”
The paramedic, Sadie Hebden, said when she got to the home, Marcus was sitting in a wheelchair in the garden. She said: “Marcus was blue. He was agitated, he had short, gasping breaths.” She slapped him hard on the back five times and his condition seemed to improve.
She was told Hanlin may have swallowed rice but was only informed that conkers had also been in the bowl while in an ambulance heading with him to hospital. She discounted conkers as the possible problem and said she could not remember passing the information on to the hospital. Hanlin died four days later.
The charity Inquest, which is supporting Hanlin’s family, said before the inquest his death is one of at least 18 since 2015 involving vulnerable people with learning disabilities who died by choking or after a swallowing incident in a care setting.
Hanlin was described by his family as a real character: mischievous, curious and interested in and affectionate towards others. He loved swimming and cycling and cooking as well as “sitting cross legged in the garden, watching the wind blow through held-up grasses or flowers”.
The inquest continues.