Philip Quelch
7 Jul 2026 · Coroner Sally Robinson · Essex
The coroner's concerns
1. inconsistent supervision during meals
“Mr [name redacted] was not consistently supervised whilst he was eating his meals”
2. lack of Best Interests Assessor involvement
“Mr [name redacted] was subject to a DOLS. It was not clear at inquest what involvement there had been with the Best Interests Assessor”
3. missing choking risk assessment and capacity assessment
“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. inadequate nutrition support guidance
“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”
5. premature closure of SALT referral
“The SALT referral was closed despite Mr [name redacted] having a co morbidities which were degenerative in nature and likely to lead to SALT issues in the future”