Man with Down's syndrome 'choked to death on conker when unsupervised'

• Marcus Hanlin died after falling ill at Cheddar Grove nursing home in Bristol
• He needed supervision around food due to swallowing issues, a court was told 

A man with Down’s syndrome choked to death on conkers after he was left unsupervised at a nursing home, an inquest has been told.

Marcus Hanlin, 57, died at Cheddar Grove nursing home in Bristol when left on his own despite a support plan which meant he should be overseen at all times when around food, a court heard.

Mr Hanlin, who had severe learning disabilities and autism, needed supervision because he had swallowing issues, according to evidence at Avon Coroner’s Court.

His family has criticised staff at the nursing home for his loss which was described as ‘beyond bearing’.

The conker had been hidden in a bowl of rice as part of a sensory activity for one of the home’s other residents.

Martin Hanlin, 57, who had Down’s Syndrome, died after choking on conkers, an inquest heard

He was taken ill in September 2022 at Cheddar Grove nursing home in Bristol

Mr Hanlin was non-verbal and lived in care facilities for most of his life, under a Deprivation of Liberty Safeguards order.

He was a resident at Cheddar Grove, a specialist facility for people with learning disabilities, when he died in September 2022.

The charity Inquest, which specialises in state institution-related deaths, says Mr Hanlin was one of at least 18 vulnerable people with learning disabilities to have died by choking in care settings over the past nine years.

And his mother Anna Rose has told the inquest: ‘The loss of his life in this manner is beyond bearing.

‘We hope others can be saved the same suffering and the same family heartache.”

She also said the Bristol Royal Infirmary had only providing a specialist disability learning nurse a limited number of times.

She added: ‘The difference the learning disabilities nurse made in her brief visit was enormous – if one had been available, this would have likely have made a big difference to his stay.”

Mr Hanlin was under an eating and drinking support plan and needed supervision whenever around food due to the risk of choking, the BBC reported.

There was a gate put in the nursing home’s kitchen to stop him getting to areas with solid food and his own meals were puréed to minimise the risk.

But on September 28, 2002, he tucked into a bowl of brightly-dyed rice prepared for another resident and swallowed not only some of the rice but two conkers.

An ambulance was called when he fell ill but paramedic Sadie Hebden was not told conkers had been in the dish until they were already en route to hospital.

She told the inquest how Mr Hanlin was in a wheelchair in the garden when she got to the nursing home, adding: ‘Marcus was blue – he was agitated, he had short, gasping breaths.’

He seemed to improve when she slapped him on the back five times but Mr Hanlin died in Bristol Royal Infirmary five days later.

He had one conker in his oesophagus and another in his stomach, though these were only found during a post-mortem, the inquest heard.

Ms Rose broke down in tears when describing his death, telling the court: ‘Marcus opened his eyes and seemed to look at us and then he was gone.’

Doctors gave the cause of death asaspiration pneumonia, Down’s syndrome, and pharyngeal and oesophageal obstruction caused by an ingested conker and aspiration of rice into the lung.

Ahead of the inquest, Mr Hanlin’s family had said in a statement: ‘As a family we are still in shock at the loss of Marcus.

‘Marcus deserves for us to do all we can to ensure the truths of what happened are reached.’

They told how he loved swimming and specialised cycling and cooking, as well as sitting cross-legged in the garden, watching the wind blow through flowers.

He was described as ‘a beloved son and brother whose loss is immeasurable’.

The inquest continues.

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