The death of a mental health patient who choked on a McDonald’s meal in an ambulance has been ruled accidental.
David Scales, 68, requested the food at Watford Gap services on the M1 in Northamptonshire, as he was taken from London to Leeds on 3 January 2017.
He fell unconscious and died on 11 January at Northampton General Hospital after a week in a coma.
An inquest jury said information about his current choking risk had not been made available to ambulance staff.
The court heard Mr Scales, from Leeds, suffered from paranoid delusional disorder and Parkinson’s Disease, and had been sectioned under the mental health act since September 2015.
He failed to return to the Mount Hospital in Leeds after four hours of unescorted leave on 2 January 2017, and was later found by police in London, who took him to Gordon Hospital.
The next day, he was handed over to private ambulance company PSS to be returned to Leeds, and the choking incident happened after he requested a stop at McDonald’s.
The jury heard Mr Scales was supervised by a mental health nurse, but the verbal handover between hospital and transport staff failed to mention his several previous choking incidents.
A nurse sister at the Mount Hospital told the court he had been working towards rehabilitation to live back in his own home and the choke risk was “not an issue”.
A verdict of accidental death by cardiac arrest was recorded at County Hall in Northampton.
The inquest heard the Gordon Hospital identified communication with PSS was “inadequate”, and that it had put “more robust” handovers in place.
PSS said staff had been given additional training and were “actively questioning” hospitals about patient risk.
Assistant coroner Jacqueline Devonish said “significant changes” had been made by all agencies involved and she would not be making recommendations.