A grandad who had been told by his family to chew his food more choked to death on his steak after not waiting for a sharp knife to be delivered to the table to cut his meal.
Derek Mitchell, 81, had been out for a meal with his family and ordered a rump which arrived without a steak knife.
Deciding not to wait for it, he choked on a large piece of meat and stood up looking for help.
An off-duty police officer in the restaurant attempted the Heimlich manoeuvre and an off-duty nurse performed CPR as someone called 999.
Two ambulances raced to the venue, but initially drove past, to the distress of his family, Dorset Live reported.
Despite their best efforts he passed away at Famous Old Spa in Weymouth, an inquest heard.
Written statements were heard from police officers and paramedics from South Western Ambulance Service NHS Foundation Trust, which noted the piece of steak was 'quite large' and the size of a ballpoint pen.
Coroner Debbie Rookes said: "Mitch had complained that when his dinner came that it didn't have a steak knife.
"He had begun eating while staff went to fetch a steak knife. Shortly after, he began coughing and stood up and he realised he was choking."
His widow said Derek, known as Mitch, was "very good natured and enjoyed lots of hobbies, he loved making everyone laugh and was a gentle kind man who loved to travel".
His family said he had previously experienced choking in two other incidents and remarked he "had always been a fast eater and was always told he needed to chew his food more".
Craig Wilkins, who conducted the critical care team review, said an air ambulance with critical care practitioners would have taken 20 minutes to reach the area, but it would not have changed the outcome.
Mr Wilkins also acknowledged there was an issue with the mapping system, which explained why ambulances initially did not stop at the pub.
Speaking directly to the family, he said "I am so sorry, it is so awful for everyone. He was out with his wife, brother-in-law and sister-in-law and having a lovely day and I am sorry about what happened."
Coroner Debbie Rookes recorded an accidental death verdict.
She said: “On January 6, 2022, Derek Mitchell was having a meal when he choked on food and became unresponsive.
"Mr Mitchell died at the scene at the Famous Old Spa pub on 229 Dorchester Road, Weymouth. The conclusion I reach is an accident. I am pleased that the trust took a clinical review of this incident and it has been very useful.
"I am pleased the trust took a clinical review of this incident and it has been very useful.
"I consider the trust has learned lessons many of which are wider than this incident itself and I know sadly nothing would have changed the outcome for Mitch."
