document: Millie Thompson died on 23 October 2012 after eating shepherd's pie at Ramillies Hall School and Nursery in Cheadle Hulme, Greater Manchester.
  An inquest jury returned a misadventure verdict, and said no-one was to blame.
  South Manchester Coroner John Pollard is writing to the government as a "matter of national importance".
  The jury at Oldham Magistrates' Court heard that Millie started coughing and crying in a high chair during her mashed lunchtime feed from a supervisor before her lips turned blue.
  A nursery supervisor - whose basic first aid certificate had expired - shouted for help and passed Millie to a colleague who had paediatric first aid training and gave the baby back slaps.
  Millie's condition fluctuated and then deteriorated as an ambulance arrived 10 minutes after staff dialled 999.
  There were no signs of life as she was taken to Stepping Hill Hospital, and she was pronounced dead soon after arrival.
  Mr Pollard also said he would be writing to the North West Ambulance Service after it emerged that the 999 call handler in the choking incident admitted she made two "fundamental" errors in responding to nursery staff's call.
  After terminating the call, North West Ambulance Service employee Aaliyah Ormerod also made the comment: "Jeez, stop giving me information," the inquest heard.
  Ms Ormerod said she had 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 accepted she should have stayed on the phone until the ambulance arrived, the inquest heard.
  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".
  Mr Pollard said he would write to the chief executive of the ambulance service regarding call handler training over child illnesses. he also said all vehicles should have appropriate paediatric equipment on board.
summary: A coroner has called for paediatric first aid training for all nursery staff after a nine-month-old baby choked while eating her nursery lunch.