At the inquest into the death of nine-month-old Millie Thompson, who choked at her nursery last year, Coroner John Pollard said he would write to the chief executive of the ambulance service to ask that all vehicles have appropriate paediatric equipment on board.
He also said he would address the subject of training for call handlers related to child illnesses.
It is extraordinarily difficult for you to relive these horrific events and I am grateful to how you have conducted yourself.
– Coroner John Pollard to Millie's parents
When counsel for the nursery offered their condolences too, Mrs Thompson said: "It's OK, I don't want them."
During the inquest it the death of Millie Thompson it emerged that the 999 call handler admitted making two "fundamental" errors in responding to the report.
After terminating the call, North West Ambulance Service employee Aaliyah Ormerod said:"Jeez, stop giving me information."
Ms Ormerod conceded in a statement to the court that she wrongly graded the call and did not recognise it as an immediate life-threatening situation which meant a rapid response vehicle was not sent to the nursery.
She also admitted she should have stayed on the phone until the ambulance arrived.
The coroner said he expected her employers to take action over the end-of-call comment which he said had "added insult to injury, quite literally".
The headteacher of the nursery where nine-month-old Millie Thompson suffered a fatal choking incident described the inquest's ruling of Misadventure as "comforting" but does not alter the fact staff at the school "continue to miss her and think of her family every day."
While today's outcome is comforting in that it confirms our understanding that we did everything we could to save Millie, it doesn't alter the fact that she's no longer with us and we'll continue to miss her and think of her family every day.
This has been a devastating time for everyone involved and we would like to thank our parents, past and present, as well as the local community for all of their words of support and comfort which have helped sustain our dedicated nursery team, who've been heartbroken by Millie's loss.
The nine-month-old baby who died after choking on food at her nursery had suffered from a rare complication during the incident, a coroner has said.
An inquest at Oldham Magistrates' Court ruled that Millie Thompson died of misadventure when she choked on shepherd's pie during lunch at the nursery in Manchester in October last year.
An expert witness in paediatrics told the inquest that the only effective treatment would have been a medical procedure where a needle is inserted to the chest.
Paramedics are trained to carry out the procedure, but the coroner said that it would have been difficult to make the correct diagnosis in such a young child and nursery staff could not be criticised for not recognising the condition.
All nursery school staff should undergo paediatric first aid training, a coroner has said at the inquest of nine-month-old Millie Thompson.
The inquest heard that when Millie began coughing during her feed, the nursery supervisor - whose basic first aid certificate had expired - shouted for help and a colleague with paediatric first aid training proceeded to give the child back slaps.
While the inquest ruled that Millie suffered from a rare complication and nursery staff could not be criticised for not recognising the condition, coroner John Pollard called on the Government to make paediatric first aid training mandatory for all nursery school staff.
Mr Pollard said that he would write to the Education Secretary Michael Gove to ask that all nursery staff have such training, "as a matter of national importance".