Butlin's holiday park has been slammed by a coroner after a toddler choked to death on a sausage while eating breakfast with his family.
James Manning, two, choked on the sausage during a holiday with his family at Butlin's in Bognor Regis, West Sussex in June 2018.
As his family battled to save little James, Butlin's staff failed to intervene.
James, from Battle, East Sussex, was to the hospital by ambulance where he was placed on life support but he died two weeks later.
His death was ruled "accidental" and intervention by staff may not have saved him, an inquest heard last year.
However, Karen Harrold, assistant coroner for West Sussex, has condemned the holiday park firm for its first aid provision.
She said she was "deeply concerned" that there was no national system for managing health and safety issues across the company's many holiday parks.
She added that there was no written procedure for staff to follow if a first aider was not immediately available.
In her Report to Prevent Future Deaths, she said: "I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with staff.
"I am concerned that the Health & Safety Executive's strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices.
"Witnesses 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."
Ms Harrold also said she was concerned that "many months" after the tragedy there were still not enough external phone lines so the emergency services could be called.
She was also concerned about insufficient defibrillators in key places such as restaurants and swimming pool areas.
James was well-known to his GP and local hospital as there had been multiple episodes of choking.
Ms Harold said at the inquest last March that James had also been "let down" by the NHS due to delays in him being assessed and treated for the choking problem.
James was on holiday with his mum Natalie Reeves and grandmother Angela Knight at the time of the tragedy.
They had made their way down to the food hall for breakfast and chose a table in the buffet area.
His mum and nan put food on a plate for James to eat and began to cut it up into bite-size pieces.
However, James grabbed a piece of sausage from the plate before it had been cut up and swallowed it.
Natalie said: "He gasped it down instead of spitting it out. I said: 'I think he's choking' but I didn't know how big it was."
She said as James struggled to breathe she grabbed him and rushed him to a member to staff in hopes someone with first aid training would be found.
She told the staff member James was choking before running outside the building to look for help.
She hit the toddler on the back and attempted the Heimlich Manoeuvre as fellow holidaymakers tried to assist.
Angela said: "There was a few staff stood around but there was no Butlin's staff that helped with James.
"There was Butlin's staff there but none of them helped. None of the first aiders assisted with James."
Paramedics in two ambulances found their passage into Butlin's blocked by gates, barriers and bollards and were forced to abandon their vehicles and continue on foot, the inquest heard.
The obstructions meant there was a delay in treating the toddler and it then took up a further seven to eight minutes to remove the sausage from his throat.
The cause of death was hypoxic-ischemic brain injury - or oxygen starvation - along with cardiac arrest following the choking incident.
In concluding her report Ms Harrold wrote to Bourne Leisure Ltd - the owners of Butlin's - and East Sussex Healthcare NHS Trust and Brighton and Sussex University Hospitals NHS Trust to take action to prevent future deaths.
A Butlin’s spokesperson said: “James's death was a tragedy and our thoughts remain with his family and friends. 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.”
