THE family of an 83-year-old man who died after choking on steak in Evesham “are upset and disagree” with a verdict of accidental death despite “harm” being caused during treatment.

Yukio Nishigaki was having a celebratory meal with his granddaughter at the Royal Oak in Evesham on March 14, 2020 when the piece of meat became lodged in his airway.

Mr Nishigaki was 300 yards away from Evesham Community Hub, the place where ambulances in the town are based when not on jobs, but there were no crews on duty at the site on the day.

The crew arrived and began treatement 11 to 12 minutes later but there was a further 16 to 17-minute delay in issuing the appropriate treatment when paramedics could not locate a laryngoscope – a piece of equipment placed into the mouth used to investigate such issues – which was later found to be where it should have been in a different bag.

That delay was brought to an end by a second crew and while Mr Nishigaki was kept alive, he had been starved of oxygen for too long and life support was withdrawn with the family’s consent two days later.

A report by West Midlands Ambulance Service (WMAS) acknowledged harm which it categorised as “severe” in its closing evaluation but coroner Geraint Williams concluded that the error could not be conclusively pinpointed as the cause of Mr Nishigaki’s death.

“We are upset and disagree,” said daughter-in-law and Evesham Town Councillor Emma Nishigaki.

“We are going to get through Christmas and regroup as a family before making a decision on what to do next.

“This is not the end of the road for this matter. We will continue to be advised and led by our legal team.”

Of greatest concern to the family is the lack of ambulance provision in Evesham that day with the report “no personnel” had been allocated to the town “due to the roster line not being fulfilled by permanent staff”.

“They say that even if an ambulance had been stationed in Evesham, there is no guarantee it would have been available,” said Mrs Nishigaki.

“Our response to that is yes, it is possible it would have been on another shout but if there is no ambulance based there in the first place then there is no chance of it being available.

“People said at the time that this would be a danger to the public. I don’t know whether this has adversely affected anybody else but if one of those ambulances on a low-priority call had been directed back to the Evesham area and they had got to him – bearing in mind he was only 300 yards from the hub – he would have survived in our opinion.

“It is our belief that systemic failings in the ambulance service, particularly the positioning of ambulances, led to his death.

“Nobody acted with malice or bad intent, they were working under extreme pressure and I believe that was created by how long it had taken to get to him.

“West Midlands Ambulance Service admitted their failures had caused him harm. We don’t hold any individual responsible for his death, it was a symptom of the systemic failing in the way that they deploy ambulances, leaving an area completely bereft, making it likely that anyone with a time-critical emergency having a negative outcome.”

In a statement, WMAS said the staffing issue had now been resolved.

“At the time of the incident, the Evesham CAS didn’t have an ambulance based there due to roster shortfalls.

“The Trust now ensures that the Evesham CAS is fully staffed and a crew is operational from there each day.”

On the issues with the laryngoscope, it added: “The staff involved were provided with further guidance and undertook a critical reflection of the case as part of the learning process.

“In addition, the Trust re-issued information to all staff reinforcing the location of the laryngoscope.”

On Mr Nishigaki’s case, it added: “We note the outcome of the inquest into the death of Mr Nishigaki, in which the coroner concluded accidental death.

“We once again send our sincere condolences to the family and friends of Mr Nishigaki for this tragic incident.”

“As a trust, we immediately carried out an internal investigation of what had happened and a number of recommendations from this have already been actioned to prevent future incidents like this happening again.”

Mr Nishigaki’s granddaughter and a waitress at the Royal Oak performed CPR until paramedics arrived with the efforts of all at the Evesham pub praised by the family.

“What the young waitress did was incredible, she was so, so brave,” added Mrs Nishigaki.