A care home in Essex has pledged to overhaul its approach to eating and drinking support following the death of a resident who choked on his lunch.
Philip Quelch, 56, died at Crouched Friars Residential Home in Colchester on July 5, 2025, after choking on a piece of ham.
He was living at the home under a Deprivation of Liberty Safeguards (DoLS) order due to safeguarding concerns in the community.
An inquest concluded on May 8, 2026, with a verdict of accidental death.
The coroner later issued a Regulation 28 report to prevent future deaths, highlighting concerns including inconsistent supervision during meals, unclear involvement of the Best Interests Assessor and communication with the home, and the closure of a SALT referral despite degenerative comorbidities.
In response, Crouched Friars has launched a new care framework called 'The Phillip Promise', designed to improve safety for residents at risk of choking.
A spokesperson for the home said: "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 an organisation, we have reflected extensively on what happened and have used this as an opportunity to strengthen our systems, improve practice and enhance the safety of all residents who require support with eating and drinking.
"Our commitment is that Phillip's death will leave a lasting legacy by improving care for others."
The Phillip Promise includes a safe eating and drinking policy, staff guidance on identifying and responding to choking risks, escalation procedures for concerns about swallowing or nutrition, and ongoing staff training.
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The home has also reviewed care plans for all residents requiring eating and drinking support, updated risk assessments, and increased referrals to speech and language therapy (SALT) where needed.
Other changes include a whole-home approach to mealtime supervision, involving non-care staff in observing and supporting residents during meals to improve safety and engagement.
The spokesperson said: "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."
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