Jurors have returned a conclusion of misadventure at an inquest into the death of a little boy who choked on food at nursery.

The five men and five women gave their finding after two hours of deliberation today into the death of nine-month-old Oliver Steeper following the incident at the Jelly Beans Day Nursery in Ashford on September 23, 2021.

Before retiring to consider the evidence heard during the eight-day inquest at Oakwood House in Maidstone, coroner Katrina Hepburn advised jurors there was “no evidence which would show failures by nursery or its staff”.

But Ms Hepburn says she will write to the Department for Education concerning some of the evidence heard to “prevent further deaths”.

She was concerned about matters of first aid, for example, some staff were not sure how firmly to slap the child’s back to deal with the choking

Ms Hepburn also offered her deepest condolences to the family adding: "I hope you have been able to understand events as far as it is possible."

Speaking after the conclusion, Oliver’s mum, Zoe Steeper, said: “We were shocked to hear various witnesses give evidence about the scene of total chaos that unfolded that day in front of many other little children.

“The nursery fed our nine-month-old baby chopped penne pasta bolognese. He choked and died. A significant amount of food debris was found blocking his lungs.

“Oli was still on milk, and we had started to move him on to pureed and appropriate finger foods at home, always under our watchful eyes.

“He had only just started teething, and only had two little bottom teeth that had started to grow. We feel he wasn’t ready for the type of meal he was given, and we maintain that we never gave the nursery permission to unilaterally make that decision.

“We entrusted Jelly Beans nursery with our most prized possession - our beautiful baby boy. We were assured that they would look after him properly. No parent should ever leave their child at nursery for them not to come home.”

A pathologist had earlier determined Oliver suffered “unrecoverable neurological damage” after a cardiac arrest caused by the choking.

The jury was told the youngster did not have any underlying condition which predisposed him to choking.

The inquest heard from several witnesses, including staff from the nursery, doctors who treated Oliver and experts such as first aid specialists about the response by nursery staff to Oliver's choking.

One expert described the basic first aid Oliver received as “poor” but could not determine if he would have survived if he had received a better standard.

The court was told harrowing details by staff including how Oliver had turned blue and stopped breathing while being fed pasta bolognese for lunch.

It also emerged during the inquest some members of staff’s paediatric first aid training had expired and they had not received any updated training which was a source of concern among colleagues.

But the nursery’s manager Debbie Alcock told the court that while her own paediatric first aid training had lapsed, “over half the staff” had current and in-date paediatric first aid certificates.

Staff member Nazia Begum recalled she was sitting with four babies and fed Oliver cut-up penne bolognese.

She told the court: “[Oliver’s] food was already pretty finely chopped up, then I chopped it up more so they were a good size.

“I remember just giving him the little teaspoon of mince.

“He had inhaled a bit of mince.

“He gagged and gasped for two to three seconds, and then he gagged again and that’s when I realised something was wrong.”

Ms Alcock said she was alerted by a panicked colleague telling her: “I think Oliver is choking.”

“Loetta was with baby Oliver over her lap and she was giving him back slaps,” said Mrs Alcock.

“I asked if anyone had checked to see if there is any food in his mouth. They said that they hadn’t checked. I asked Haiga to check his mouth and she did, but not successfully.

“As she was checking, he bit down on her finger and out of reflex or whatever, she laughed, and at that point I took the baby because the child was clearly dying.

"I carried Oliver outside upside-down, which I accept is not a recommended practice.

“He was the most shocking colour of blue and purple that I’ve ever seen in a baby.

“I’ve never seen a baby’s face like that before.

Oliver’s mum Zoe Steeper told the court at the start of the inquest she had conversations with nursery staff about her son’s eating habits at home and that he was not eating solid foods at home except for occasional finger-food snacks.

She said staff told her that would be fine “because they had a blender and that his main food would be puréed”.

But Ms Begum told jurors she could not recall having a detailed conversation with Mrs Steeper about Oliver’s food.

“I didn’t really have a clear understanding of what he could have,” said the carer.

“I just remember having a general chat with Mrs Steeper but I don’t remember any specific information about what he could have.

“I usually had a general chat with all the parents, but if I wasn't the key person I wouldn’t go into too much detail because I knew that the key person would do that.”

Ms Alcock said she expected Oliver to receive “textured food”.

She explained this would include “some lumps in their food to encourage them to accept those lumps, some finger foods like toast or banana”.

The Steeper family’s solicitor Jill Paterson said after the conclusion: “Oli’s death was an unimaginable tragedy and one that no parent should have to endure.

“Despite the devastating grief our clients have had to go through, they are fully committed to ensuring that important lessons are learned from this terrible incident and that nurseries and other early childhood settings become safer places in future.

“Urgent action must be taken by all those involved in the early years sector, including regulators, legislators and childcare providers, to ensure that this appalling tragedy that cost the life of a baby boy never happens again.”

Mrs Steeper added: ““Hundreds of thousands of children are looked after by nurseries every day in the UK.

“It generates an estimated income of £4.7 billion pounds each year. It is big business.

“Oli’s case has shone a light on what we feel are loopholes in the way nurseries are allowed to care for young children and babies.

“We have waited more than two and half years for Oli’s voice to be heard.

“We now want to see meaningful change to ensure that no other family has to go through the heartbreak of losing a baby in this way whilst in the care of others.”

Oliver died six days later on September 29, 2021 at the Evelina Children’s Hospital in London.