18/09/2026
💙 Turning Tragedy into Learning, Reflection and Positive Change 💙
Within health and social care, it is crucial that we take the time to learn from incidents, reflect on what has happened, and continually look for ways to improve the quality and safety of the care we provide to the individuals and communities we support.
Sadly, a tragic incident occurred in which a gentleman, Phillip, sadly choked on a piece of ham, resulting in his accidental death.
Our heartfelt thoughts go to Phillip's family, friends and the staff team who knew, loved and cared for him. 💙
While this is an incredibly sad loss of a wonderful man, I would like to take a moment to recognise and applaud Crouch Friars Care Home in Colchester for responding proactively and using this tragedy as an opportunity to strengthen their existing approach to eating and drinking safety.
They have implemented **Phillip’s Promise**, a safety initiative designed to strengthen protocols around Recognising, Responding to and Reporting eating and drinking difficulties.
This is exactly where meaningful learning can begin.
Rather than simply asking "What went wrong?”, we should also be asking:
🔹 Could our existing policies and procedures be strengthened?
🔹 Could Phillip’s Promise help us further enhance our protocols and practice?
🔹 Are all staff confident in the fundamental principles of nutrition and hydration?
🔹 Do staff understand MUST, food types, textures and individual dietary requirements?
🔹 Are our staff appropriately trained and competent in responding to a choking emergency and providing lifesaving first aid?
🔹 Are we confident that our care plans clearly identify individual eating and drinking risks and the actions required to keep people safe?
These are questions that every care provider should be asking, regardless of whether an incident has occurred within their own service.
There may be debate about whether this tragic death could have been prevented. But rather than allowing that debate to become about blame, let us use this moment to productively and purposefully:
👉 Don't waste time pointing fingers.
👉 Use the opportunity to learn.
👉 Reflect on your practice.
👉 Strengthen your systems.
👉 Invest in your staff.
👉 Put safety at the heart of everything you do.
Phillip’s story should never simply become another incident report that is filed away.
Let it be a catalyst for change. ❤️
Let it encourage every care provider, every manager and every member of staff to stop, reflect and ask:
“What more can we do to keep the people we care for safe?”
If even one service strengthens its practice, one team becomes more confident, or one future tragedy is prevented because someone learned from Phillip's story, then something positive can come from an incredibly painful situation.
Learn. Reflect. Improve. Protect.
Because ultimately, that is what person-centred care and a culture of safety should be about — achieving better outcomes for the people who need us most.💙
