The death of a two-year-old girl who choked on a cocktail sausage was caused by misadventure, a coroner has ruled.
Mia Atkins died in hospital on 1 July 2018 after her airway became blocked at home in Greenhithe, Kent.
Her parents argued medical staff made a number of errors which led to their daughter’s death.
But Coroner Roger Hatch said it was a “difficult situation” and Mia’s chance of survival had been “extremely slim”.
The inquest at Maidstone Coroner’s Court heard about delays in answering 999 calls and a five minute wait for an anaesthetist after a “miscommunication”.
It also heard a tube that should have been in Mia’s windpipe had been found in her oesophagus.
But Mr Hatch said, having considered a report from South East Coast Ambulance Service and Dartford and Gravesham NHS Trust, steps had been taken to prevent it happening again.
He said after “unfortunate delays”, once dispatched the ambulance arrived with “commendable speed”.
An experienced paramedic was met with a serious and difficult situation and Mia’s chance of survival was extremely slim, he added.
Speaking after the ruling, Mia’s mother, Beth Ranger, said she was “disappointed” and would be looking at taking further action.
Mia was at home in Greenhithe when her aunt noticed she was struggling and started slapping her back.
Ms Ranger made several 999 calls but struggled to get through, partly because of problems with the phone signal.
She performed CPR while waiting for the ambulance but said Mia started “turning blue” and bleeding from her nose and mouth.
The inquest was told that after paramedics arrived, information was not correctly passed on between nursing staff at the hospital.
As a result, a cardiac arrest call was not put out and there was a delay of five minutes before an anaesthetic doctor attended.
The family’s solicitor, James Weston, said had the anaesthetist been there immediately, the tube could have been replaced in the windpipe five minutes earlier.
He said it was arguable the tube had been put in the wrong place by a paramedic, but Mr Lyle said it could have come out during transit or transfer.
A post-mortem examination gave Mia’s cause of death as upper airway obstruction.
A report prepared by the ambulance service found delays in answering the calls were due to a combination of “high demand and below effective staffing”.
The trust said it had recruited more call-handlers and was working on staff retention.
In delivering his verdict, the coroner noted an incident the previous month where Mia had started to choke on a mint, and he suggested that giving her a cocktail sausage had been “unwise”.
He said he was satisfied the appropriate conclusion for the death was misadventure.