Philip Quelch

Dear HM Assistant Coroner Robinson Prevention of future death report following inquest into the death of Phillip Quelch Thank you for bringing the Regulation 28 prevention of future death report to the attention of the Care Quality Commission (CQC) following the inquest into the sad death of Phillip Quelch who died on 5 July 2025 at Crouched Friars Care Home (‘Crouched Friars’). We acknowledge the concerns you have raised and appreciate the opportunity to respond. We would like to express our sincere condolences to the family of Mr Quelch. We note the legal requirement upon CQC to respond to your report within 56 days of the date of the report, namely by 1 September 2026. The registered provider of Crouched Friars is SA & JO Care Limited. They have been registered with CQC since 13 October 2011. The provider is registered for the following regulated activity: Accommodation for persons who require nursing or personal care. The provider is not permitted to provide nursing care at this location. Crouched Friars was inspected on 15 and 27 September 2022 and was rated Good in key questions: Safe, Effective, Responsive and Well Led, and rated Good overall. Caring was not reviewed. Improvements had been made following the previous inspection carried out in May 2021 and they were not in breach of Regulations.

[Page 2] CQC received a statutory notification of a death in a care home from Crouched Friars on 15 July 2025 informing us of an unexpected death. Cause of death at that time was not known. CQC requested the registered manager for Crouched Friars to advise CQC of the cause of death as soon as it was known. On 6 October 2025, the deputy manager of Crouched Friars told CQC they had been informed the coroner had opened a coronial investigation into the death of Mr Quelch and that the postmortem concluded the cause of death to be from an airway obstruction caused by food stuck around epiglottis. CQC has responsibility for prosecuting registered persons (this includes registered providers and registered managers), where it can be shown to the required evidential standard that failures to provide safe care and treatment led to a person using services experiencing avoidable harm, or placed them at serious risk of such harm (contrary to Regulations 12(1) and 22(2), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). In such cases CQC can only hold the registered person(s) to account (registered provider and registered manager), we are unable to hold individuals such as nursing staff and care workers to account. Preliminary enquiries were commenced into the circumstances surrounding Mr Quelch’s death. The coroner granted CQC interested person status and shared the fully completed evidence bundle with us on 5 May 2026. We considered if there was sufficient evidence to take further action relating to Regulation 12(1) Safe care and treatment in relation to Mr Quelch. Following a full review of all the evidence CQC concluded we did not have grounds to begin a criminal investigation. CQC will continue to monitor the service utilising information obtained from our insight data as well as other stakeholders such as the local authority. We will use our regulatory processes to assess, and where necessary civil enforcement pathway to drive improvement. Regulatory assessments will be undertaken when and where required. Once an assessment is completed a report will be published on the CQC website with our findings. Matters of Concern
1. Mr Quelch was not consistently supervised whilst he was eating his meals CQC contacted Crouched Friars to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report. We received a response by return, Monday 27 July 2026 which informed us of the following:

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• From extensive review and reflection on the circumstances surrounding the sad death of Mr Phillip Quelch lessons have been learned.
• This led to the registered manager, Paulina Eagle developing ‘The Phillip Promise’. A comprehensive framework to improve their approach to delivering person-centered, safe, responsive and consistent care and support to people with or developing swallowing difficulties and at risk of choking. On review of the document, we contacted Crouched Friars to revise the Phillip Promise policy to include:
• A policy for people who eat alone in their bedrooms
• Risk assessments for those people eating alone in their bedrooms – particularly those at risk.
• More detail on the type and level of supervision required as supervision can be interpreted differently by individuals. The registered manager for Crouched Friars has since reviewed and revised the first version of the Phillip Promise Policy to include all the above. The policy and implementation of it will ensure the correct safeguarding measures are in place to protect people and reduce the risk of choking. CQC will continue to monitor the provider’s compliance with regulatory standards and ensure that learning from this case is embedded into practice. We remain committed to supporting improvement in patient safety and care quality across all services.
2. Mr Quelch was subject to a DOLS. It was not clear at inquest what involvement there had been with the Best Interests Assessor.
3. If a Best Interests Assessor notes an adult is at risk of choking, then they should check a choking risk assessment has been carried out and there should be an assessment of capacity under the Mental Health Capacity Act.
4. If these have not been done, then The Best Interests Assessor should consider a recommendation under the DOLS that the adult should receive appropriate guidance and support when accessing nutrition. It was not clear whether these steps had been taken in Mr Quelch’s case and what the communication was between the Best Interests Assessor and the residential home. CQC has considered points 2, 3 and 4. CQC notes that this Prevention of Future Deaths has been sent to Essex local authority Adult Social Care. CQC considers they may be of greater assistance in addressing these aspects of your concerns.
5. The SALT referral was closed despite Mr Quelch having co-morbidities which were degenerative in nature and likely to lead to SALT issues in the future. We would expect SALT services to have effective processes in place to assess, monitor and manage swallowing risks, with decisions regarding assessment and

[Page 4] discharge based on the person's needs and supported by appropriate documentation and clinical judgement. We have ascertained from the East Suffolk and North Essex NHS Foundation Trust (ESNEFT) that a referral was made, by the care home, on 17 December 2024. This followed Mr Quelch choking on a wrap on that same day and required emergency intervention. It was also noted that Mr Quelch had learning disabilities and epilepsy. The referral was triaged by the SALT team who documented Mr Quelch had a low level of complexity and sought further information from the care home. At this point the care home noted this was an isolated incident. Written guidance was provided to the care home, along with recommendations to keep a cough diary and avoid high risk foods for example. On 23rd January 2025 the SALT team sought an update from the care home. The care home staff member spoken with advised the SALT team the concerns were an isolated incident and they were happy for Mr Quelch to be discharged. A discharge letter was sent to the GP. The SALT team have reflected on their management of the referral of Mr Quelch to their service. They have identified that they could have asked for further information about the cough diary it was recommended the care home maintain. They have identified greater detail in recording how the available information informed the clinical decisions would have been beneficial. We will take account of this reflection in our ongoing monitoring and regulation of the service.

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Senior Coroner for the Coroner Area Essex in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Philip Andrew QUELCH, and an inquest that concluded on 08 May 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Essex County Council provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE
26.08.2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Mr Quelch was not consistently supervised whilst he was eating his meals. (2) Mr Quelch was subject to a DOLS. It was not clear at inquest what involvement there had been with the Best Interests Assessor. (3) If a Best Interests Assessor notes an adult is at risk of choking, then they should check a choking risk assessment has been carried out and there should be an assessment of capacity under the Mental Health Capacity Act. (4) If these have not been done, then The Best Interests Assessor should consider a recommendation under the DOLS that the adult should receive appropriate guidance and support when accessing nutrition. It was not clear whether these steps had been taken in Mr Quelch’s case and what the communication was between the Best Interests Assessor and the residential home. (5) The SALT referral was closed despite Mr Quelch having a co morbidities

[Page 2] which were degenerative in nature and likely to lead to SALT issues in the future.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. No action is proposed. Essex County Council (ECC) is concerned that the Prevent of Future Deaths (PFD) report was issued in circumstances which were procedurally unfair and where the evidential basis for the concerns expressed were incomplete. ECC was not designated as an Interested Person pursuant to section 47 of the Coroners and Justice Act 2009 and therefore not afforded any meaningful opportunity to participate in the investigation or inquest process. Whilst it is recognised that there is no absolute statutory requirement for a coroner to invite representations from a potential PFD recipient before issuing a report, the coroners discretion to make a report under paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 must nevertheless be founded upon the relevant and sufficiently informed evidence and information available to the coroner. Fundamental principles of fairness require that where concerns are to be expressed regarding practice, procedures and decision making which might have been capable of being explained, or materially qualified, the coroner should wherever possible have access to evidence capable of explaining those matters before reaching conclusions that may form the basis of a PFD. The Chief Coroners guidance emphasises that PFD reports should be based on clear evidence and that the coroner must consider all relevant documents, evidence and information before making the report. That concern is compounded by the absence of live evidence from the Best Interests Assessor (BIA). Had the BIA been called to give evidence the coroner would have been able to consider first had evidence regarding the statutory assessment process undertaken, information available to the BIA at the time, professional judgement, the scope and limitations of the role. This evidence would have materially assisted the coroners understanding of the process of DoLS authorisation and may have materially altered the factual evidential picture upon which the PFD concerns were based. The Role of the Best Interests Assessor The Deprivation of Liberty Safeguards (DoLS) process was implemented in 2009 as an amendment to the Mental Capacity Act 2005. The DoLS are statutory protections within the Mental Capacity Act 2005 that authorise and review situations where a person who lacks capacity is deprived of their liberty in a hospital or care home, ensuring the arrangements are lawful, necessary, proportionate and in the person's best interests. A DoLS assessment has to be carried out by a Best Interest Assessor (BIA) and a Section 12 Doctor (for the mental health assessment element). A Best Interests Assessor is a registered professional, who has undertaken specific BIA training. They are employed by the Supervisory Body (Local Authority) and are responsible for assessing whether a person who lacks capacity is being deprived of their liberty and whether

[Page 3] the arrangements are necessary, proportionate, and in the person's best interests under the Mental Capacity Act and DoLS framework. The whole process follows six assessments which are as follows:
1. Age Assessment – determines the age of the person as DoLS applies to people aged 18yrs and over only.
2. Mental Health Assessment which establishes whether the person has a mental disorder as defined by the Mental Health Act 1983 (this is completed by the section 12 doctor).
3. Mental Capacity Assessment which is completed by the Best Interest Assessor. This assessment focuses on establishing whether the person lacks capacity to consent to the care and treatment arrangements that may amount to a deprivation of liberty.
4. No Refusals Assessment which is a check to understand whether the proposed arrangements conflict with a valid Advance Decision, or the decision of an attorney or deputy with relevant authority
5. Eligibility Assessment, which determines whether the person is eligible for DoLS. This should consider whether the Mental Health Act should be considered for any deprivation instead of the DoLS process.
6. Best Interests Assessment, which considers whether the person is being deprived of their liberty, and if so, whether this is this is necessary to prevent hard, proportionate and least restrictive in nature. Only once these assessments have taken place can a decision be made to either authorise or not grant a DoLS. The role of the BIA is therefore to review existing arrangements, consider whether the restrictions are lawful and proportionate, and make recommendations or suggest conditions to reduce the impact of the deprivation of liberty. They would only make recommendations or suggest conditions where there is a need to strengthen what is already in place. a BIA is not responsible for:
• Developing or implementing care plans within the care setting
• Undertaking routine care management.
• Managing identified risks on a day-to-day basis.
• Completing or owning service risk assessments.
• Deciding the person's package of care or funding arrangements.
• Directly supervising staff or overseeing the quality of care delivery.
• Making operational decisions on behalf of the care provider. The responsibility for care planning and risk management remains with the Managing Authority (the hospital or care home). In the situation of Mr Quelch, the BIA reviewed all care plans and risk assessments, and there were no concerns raised in relation to how nutrition and hydration were being managed, therefore they did not make any recommendations or conditions to amend/strengthen what was already in place.

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5. DETAILS OF FURTHER ACTION PROPOSED Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online.
6. Head of Safeguarding MCA & DoLS

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Senior Coroner, [X] for the Coroner Area Essex in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Philip Andrew QUELCH, and an inquest that concluded on 08 May
2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, NAME provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 24/07/2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Mr Quelch was not consistently supervised whilst he was eating his meals. (2) Mr Quelch was subject to a DOLS. It was not clear at inquest what involvement there had been with the Best Interests Assessor. (3) If a Best Interests Assessor notes an adult is at risk of choking, then they should check a choking risk assessment has been carried out and there should be an assessment of capacity under the Mental Health Capacity Act. (4) If these have not been done, then The Best Interests Assessor should consider a recommendation under the DOLS that the adult should receive appropriate guidance and support when accessing nutrition. It was not clear whether these steps had been taken in Mr Quelch’s case and what the communication was between the Best Interests Assessor and the residential

[Page 2] home. (5) The SALT referral was closed despite Mr Quelch having a co morbidities which were degenerative in nature and likely to lead to SALT issues in the future.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here. If you feel that the response should not have been sent to you, please state this]. Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 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 Following this incident, I developed The Phillip Promise – a comprehensive safe eating and drinking framework designed to ensure that every resident at risk of choking receives safe, person-centred and consistent care. The Phillip Promise includes:  A Safe Eating and Drinking Policy..  Staff guidance on recognising and responding to choking risks.  Clear escalation procedures where there are any concerns regarding swallowing, food textures, hydration or changes in a resident's condition.  Guidance on Mental Capacity Act (MCA), Best Interest decision-making and DoLS where appropriate.  Ongoing competency expectations and continual staff learning. The aim of The Phillip Promise is to ensure that no concern, however small, is overlooked and that residents always receive the safest possible support during mealtimes. Care Plan and Risk Assessment Review Following the incident, we completed a comprehensive review of all residents who require support with eating and drinking. This included:  Reviewing every choking risk assessment.

[Page 3]  Reviewing all nutrition and hydration care plans.  Sending more SALT referrals and discussing the diet levels with the GP while we are awaiting SALT assessment as it can take few weeks or months  Ensuring all care plans accurately describe the level of support required.  Confirming that prescribed food textures and fluid consistencies are recorded correctly in line with current SALT recommendations.  Ensuring care plans clearly state the supervision required, positioning, pace of eating, equipment required and actions to take should a resident deteriorate or show signs of swallowing difficulties. Staff Learning and Reflection The circumstances surrounding Mr Quelch's death have been openly discussed during staff meetings, supervisions and team learning sessions. Staff have been reminded that:  Every concern relating to eating, drinking or swallowing must be reported immediately.  Changes in a resident's presentation, appetite, coughing, choking, voice quality or ability to swallow must never be ignored.  Concerns must be escalated promptly to senior staff and referred to the appropriate healthcare professionals, including Speech and Language Therapy (SALT), where required.  Accurate documentation and communication between all members of the multidisciplinary team are essential. This learning has reinforced a culture where speaking up and acting early is expected of every member of staff. Whole Home Mealtime Support We have introduced a whole-home approach to mealtimes. Rather than mealtimes being the responsibility of care staff alone, housekeeping, activities and other non-care colleagues now assist by supporting observation, encouraging residents, providing reassurance and alerting care staff immediately if they notice any concerns. This approach has increased supervision during meals, improved resident engagement and reduced the likelihood that subtle signs of difficulty are missed. Ongoing Quality Assurance To ensure these improvements are sustained, we have introduced ongoing monitoring through:  Regular audits of eating and drinking care plans.  Routine reviews of choking risk assessments.  Mealtime observations.

[Page 4]  Continued staff training and competency assessments.  Regular discussions during staff meetings and clinical governance reviews.  Immediate review of any incidents, near misses or concerns relating to eating and drinking. 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, and that the lessons learned from this tragedy continue to improve the quality and safety of care for all those we support. .
5. DETAILS OF FURTHER ACTION PROPOSED Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online.
6. SIGNATURE