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Man swallowed conkers and choked to death in Bristol, inquest hears

A man with Down’s syndrome choked to death on conkers after being left unsupervised in his care home, an inquest has heard. Marcus Hanlin, 57, was a resident at Cheddar Grove Nursing Home where his mother says he was on a support plan requiring him to be supervised at all times while around food, due to swallowing issues.

Charity Inquest said Mr Hanlin had an eating and drinking support plan due to his particular needs around food and swallowing, which were regularly assessed by Speech and Language Therapy services. He had an identified risk of choking and required constant supervision around food while living at the care home in Bedminster Down.



On September 28, 2022, Mr Hanlin was left unsupervised with a bowl of dyed rice with conkers hidden inside. The dish was part of a sensory activity for another resident at the home.

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An inquest held at Avon Coroner’s Court at Flax Bourton was told he swallowed two conkers and some undyed rice. He became unwell and was taken to Bristol Royal Infirmary.

Mr Hanlin’s condition deteriorated and he died five days later. His cause of death was given as aspiration pneumonia and pharyngeal and oesophageal obstruction due to ingested conker and aspiration of rice into the lungs. The conkers inside his lungs were only discovered after Mr Hanlin’s death.

According to Inquest, which investigates deaths involving state institutions, Mr Hanlin is one of 18 people with learning disabilities and/or autism who died by choking or a swallowing incident in a care setting since 2015.

Marcus’s family said: “As a family we are still in shock at the loss of Marcus. The nature of how this came about, the pain and fear Marcus suffered and the loss of his life in this manner are beyond bearing.

“Marcus deserves for us to do all we can to ensure the truths of what happened are reached and we hope others can be saved the same suffering and resultant family heartache.”

Speaking to the BBC, mother Anna Rose criticised Cheddar Grove over a lack of supervision. She said: “At no time did any one from Cheddar Grove or hospital say Marcus had swallowed conkers. We understand Marcus had swallowed dried rice and two conkers – this was an incredible shock.

“We wondered if this had been discovered through additional tests and that something so predictable could have been allowed to happen. The loss of his life in this manner are beyond bearing. We hope others can be saved the same suffering and the same family heartache.”

She also spoke of her frustration with Bristol Royal Infirmary, which she said only provided a specialist disability learning nurse on a number of occasions: “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.”

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