A CORONER has said lessons need to be learned after a toddler died choking on a sausage at a holiday park.

Two-year-old James Manning, who had enlarged tonsils and had suffered 'dozens of choking incidents' prior to his death, choked on the piece of sausage while at Butlin’s in Bognor with his family in June 2018.

Despite getting CPR and first aid the sausage could not be dislodged and it took paramedics seven to eight minutes to remove the piece of food by using a laryngoscope and Magill forceps.

James suffered a seven-to-eight-minute cardiac arrest causing a hypoxic ischaemic brain injury, caused by a lack of oxygen to the brain.

He was stabilised and taken to Southampton General Hospital where despite treatment in PICU his life support was withdrawn and he died on June 20, 2018, two weeks after the incident.

Read more: Toddler's tragic death at holiday park was accidental - inquest finds

Assistant coroner Karen Harrold ruled in conclusion at James’ inquest in March 2021 that his death was accidental, but that the youngster had been “let down” due to “red flags” being missed in regard to his enlarged tonsils.

James, from Battle, was well-known to his GP and local hospital (Conquest Hospital) as there had been multiple episodes of choking.

"The NHS did let James down as an earlier intervention may have reduced the chances of James choking on June 6, but I cannot conclude that James's life would have been saved by an earlier intervention,” said Ms Harrold during the inquest at Crawley.

And now in a new prevention of future deaths report Ms Harrold raised several concerns to the NHS and Butlin's.

She said GPs and doctors could benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment, also that further guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care and the inclusion of choking in the ENT UK Commissioning Guide for Tonsillectomy.

She also raised concerns about the delay in James being reassessed and referred for further care, particularly after he was referred for a sleep study following concerns about sleep apnoea, which was exacerbated by staff being on leave.

And she said systems to review how information is shared locally may need to be “reconsidered”.

“Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases,” she said.

She called on Bourne Leisure (which incorporates Butlins) to develop a national system for managing health and safety across its sites.

She expressed “deep concern” about whether there was a “sufficiently robust” incident investigation and reporting system in place so that “lessons could be learned” and then shared with staff.

Ms Harrison was also concerned to hear evidence that many months after the incident, installation of an external phone line and sufficient automated external defibrillators in key areas such as restaurants and swimming pool areas had not been completed.

And she said witnesses during the inquest investigation confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999 emergency call, especially if a trained first aider is not immediately available.

A Butlin's spokesman said all the recommendations from the coroner's report had been implemented.

“James's death was a tragedy and our thoughts remain with his family and friends," he said.

"The safety and wellbeing of our guests is always our priority, and we can confirm the recommendations from last year’s report have been implemented.”

Ann Dunn, 65, died following the attack at a home in Kirkdale, Liverpool, on Monday.

Both Kevin Curtis and John Guinn climbed the career ladder after studying on Coursera

GOP Senate hopeful Kari Lake uses Russian troop stock footage in campaign ad promising to ‘secure our border’Kari Lake

Kourtney Kardashian Opens Up About Being ‘So Into’ Her ’Thicker Body’ After IVF

The number of company insolvencies in England and Wales hit its highest level for 13 years in the second quarter of the year, according to official figures.

Experts claim that deadly spillovers of disease between livestock and wildlife are increasing with the growth in intensive methods

Prince Harry undertakes another battle in his war against the tabloid press and alleges the Daily Mail has been involved in phone hacking and police corruption.

Local TD Pearse Doherty said silent prayers were being said as people awaited news from the emergency services.

Meeting could be committee’s last public event

It comes as public inquiry hears evidence from parents of children affected

The 26-year-old actress arrived at the film’s UK premiere at the BFI London Film Festival.

While the effects on the election from news on Hunter Biden are unclear, it will likely give Republicans something to probe if they win back the House of Representatives

In today’s newsletter: One million people have already been displaced by the country’s third famine in ten years. This is how Somalia found itself in a dire situation once again

Joey Essex has signed up for 'Dancing on Ice' and wants to be "cursed" with a new love.

People return to vaccine centres across the UK to receive their autumn booster vaccine against covid. Despite recent rising numbers of infection, people at this vaccine centre in Cambridge say they are “not over worried at the moment” and believe the vaccine will give them an “extra layer of protection” from the virus this winter. .

The former England hooker opened up on his early onset dementia.

At least three students died after a wall collapsed at MTsN 19 School in Jakarta, Indonesia, today (October 6). The wall fell after heavy rains hit the city and caused severe floods. Dramatic footage shows scared and screaming students looking down from the upper floor of the school as rain pours down. Young people can be seen trying to climb the building to seek shelter. The collapse of the wall occurred at approximately 2.50 pm, Western Indonesian Time. Multazam Lisendra, a police chief, told broadcaster Kompas TV that the cause of the incident needs to be investigated further, but they assume that the near overflowing river added pressure to the already precarious situation. Many students were injured. All victims have been taken to Prikasih Hospital.

A growing list of failings and military defeats in Ukraine have spawned angry outbursts from members of the Russian elite – including lawmakers, media figures and at least one former general – who generally still support Vladimir Putin's "special military operation" but are now actively blaming army chiefs for a slew of military reversals. Public criticism of the army was very rare before September saw a series of high-profile battlefield reversals for Russian troops. The Russian invasion that b

For Thursday’s show, the presenter opted for a leather midi skirt and sleek white blouse

The Conservatives have fallen 37 points behind Labour in London, according to a new analysis which suggests all their MPs in the city would be at risk of General Election defeat. The MRP polling by Survation for campaign group 38 Degrees put Labour on 59 per cent in the capital, the Tories 22 per cent and Lib-Dems 13 per cent. The headline figure for the capital is similar to the London sample of other recent polls, of a Labour lead of 44 per cent in a YouGov survey.