Butlin's introduces coroner's recommendations after two-year-old boy choked to death on a sausage in Bognor Regis

James Manning, from Battle, East Sussex, choked while on holiday at Butlin’s in Bognor Regis in June 2018 and died days later in hospital.

Following the tragedy, a spokesperson said Butlin’s has introduced all of the measures recommended in a coroner’s report published last year.

“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,” they said.

"James’s death was a tragedy and our thoughts remain with his family and friends.”

The recommendations, made by coroner’s assistant Karen Harrold, included a national system for managing health and safety across sites, a written standard operating procedure setting out when to make a 999 emergency call and how to get first aid help quickly and the installation of an external phone line and defibrillators in areas like restaurants and swimming pools.

The incident took place on June 6 as the family breakfasted at the resort’s Ocean Drive restaurant. James grabbed a large piece of sausage and ‘gasped it down’ before his mother, who was busy cutting up the rest of his food, could stop him.

Bystander CPR and first aid were not enough dislodge the meat and 999 was called. It took paramedics seven to eight minutes to remove the sausage using a laryngoscope and forceps, enough time to send the toddler into cardiac arrest, the inquest heard.

He sustained a hypoxic ischaemic brain injury and was taken to Southampton General Hospital. Extensive treatment at the Psychiatric Intensive Care Unit (PICU) was not enough to drive his recovery and he died on June 20, after his life support systems were withdrawn.

Coroner’s assistant Karen Harrold told the inquest the death was ultimately accidental, but made clear James had been ‘let down’ by a number of delays to treatment of his pre-existing condition.

The little boy was well known to his GP and local hospital, having been treated for a number of previous choking incidents. At the time of the final incident he was on a list for surgery to get his tonsils removed and had previously nearly died after eating a piece of chicken which, caught in his throat, choked him for two minutes.

"The delay in being reassessed and referred to tertiary care was contributed to by medical staff being on leave,” she explained. “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.”

She suggested GPs and hospitals would benefit from national guidance about referring children for tonsillectomy treatments, as well as additional guidance to help doctors decide which cases need tertiary care or an urgent referral to hospital. The inclusion of choking in the ENT UK commissioning guide for Tonsillectomy was also suggested.

Ms Harrold also questioned the way hospital share information locally, suggesting a review of procedure: “I am concerned that systems to review how information is shared locally may need to be reconsidered,” she said.

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