Story Highlight
- Philip Quelch, 56, died from choking on ham in Colchester.
- He lived under a Deprivation of Liberty Safeguards order.
- Inquest verdict was accidental death on May 8, 2026.
- Crouched Friars launched ‘The Phillip Promise’ for resident safety.
- New policies aim to improve mealtime supervision and training.
Full Story
Philip Quelch, aged 56, passed away at Crouched Friars Residential Home in Colchester on July 5, 2025, after choking on ham. At the time of his death, he was residing in the home under a Deprivation of Liberty Safeguards (DoLS) order due to safeguarding issues in the community.
An inquest into his death concluded on May 8, 2026, determining the cause to be accidental. Following the inquest, the coroner issued a Regulation 28 report aimed at preventing future fatalities, highlighting several concerns. These included inconsistent supervision during meal times, ambiguity regarding the role of the Best Interests Assessor, and inadequate communication with the care home. The report also noted the closure of a referral to speech and language therapy (SALT), despite Mr Quelch’s existing degenerative health issues.
In response to these findings, Crouched Friars has introduced a new comprehensive care initiative named ‘The Phillip Promise.’ This framework aims to enhance safety for residents at risk of choking. A spokesperson for the home stated, “The death of Mr Phillip Quelch had a profound impact on everyone at Crouched Friars Residential Home. We remain deeply saddened by the circumstances surrounding his death and sincerely regret that we were unable to prevent this tragic event.”
As part of ‘The Phillip Promise,’ the residential home has implemented a safe eating and drinking policy, provided staff with guidance on recognising and addressing choking hazards, established escalation procedures for issues related to swallowing and nutrition, and committed to ongoing staff training. Additionally, care plans for all residents needing assistance with eating and drinking have been thoroughly reviewed, with updated risk assessments and increased referrals to speech and language therapy where necessary.
The initiative also encompasses a holistic approach to mealtime supervision, involving non-care staff in observing and supporting residents during meals to enhance safety and engagement. The spokesperson added, “Phillip’s death has fundamentally changed the way we approach eating and drinking safety within our home. Through The Phillip Promise, we are committed to ensuring that every resident receives safe, compassionate and person-centred support.”
Source: read the original report.
What this means for your site
In the tragic case of Philip Quelch’s choking death at Crouched Friars Residential Home, multiple opportunities for better adherence to safety practices were evident. Inconsistent supervision during meals highlighted a critical flaw in compliance with the Health and Safety at Work etc. Act 1974, which ensures the safety of employees and residents in care settings. The Management of Health and Safety at Work Regulations 1999 also apply, as they mandate risk assessments and the implementation of necessary precautions to prevent such incidents.
To prevent similar occurrences, sites should establish clear protocols for supervision and support during mealtimes, ensuring that all staff are trained in identifying choking risks and respond appropriately. Regular reviews of individual care plans can be reinforced by utilising oversight mechanisms like staff checklists to guarantee adherence to supervision policies. Additionally, fostering communication between staff and healthcare professionals when it comes to residents with special dietary needs or swallowing difficulties is essential for ensuring comprehensive care. These proactive measures can significantly enhance the safety and well-being of vulnerable individuals in care environments.
