Care home pledges to improve after patient's choking death

A care home resident who died after choking on a piece of ham "should have been supervised" during his meals, a report has concluded.

Philip Quelch, 56, died at Crouched Friars Residential Home in Colchester on 5 July 2025 as a result of choking on a large piece of ham during his lunch.

Quelch lived in the home because of safeguarding concerns and he had an in-life diagnosis of vascular dementia and neurofibromatosis.

Sally Robinson, assistant coroner for Essex, has set out her concerns in a prevention of future deaths report in which she said Quelch was not consistently supervised whilst eating meals. The home said it had now improved safety for its residents.

The incident came after his family reported he needed help with eating and drinking, and his care notes documented that he was unable to meet his nutritional and hydration needs independently.

Quelch had a previous episode of choking at the home and had been referred to a speech and language therapy (SALT) service which supports people with communication and swallowing difficulties.

He did not attend an appointment due to the waiting list, but after he did not have any more choking episodes, the referral was closed.

On the day he died, he had chosen a ham salad for his lunch and the report said he was left with his meal.

He was subsequently found unconscious and unresponsive at 15:15 BST, his meal having been delivered between 12:30 and 12:45 and a further check made at around 13:30 and around 14:00.

Staff and then paramedics carried out CPR but Quelch could not be revived.

The incident has led the care home to implement a new framework called "The Philip Promise" - designed to reduce the risk of choking.

An inquest that concluded on 8 May found the cause of death was accidental.

The care home said: "The death of Mr Philip 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 Philip's death will leave a lasting legacy by improving care for others."

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