A jury will decide whether more could have been done to save a man who choked on a McDonald's meal in Northampton and died.
David Scales, 68, died on January 11, 2017 in Northampton General Hospital after he choked on the food on January 3, while being transported from London to Leeds.
NGH is not being investigated as part of the inquest.
He had been in an induced coma after suffering a heart attack.
Launching a four-day inquest into his death yesterday, assistant coroner Jacqueline Devonish told members of the jury there was no suspicion of deliberate wrongdoing and that the purpose of the inquest was to identify any systemic failures or dangerous procedures.
The inquest heard Mr Scales suffered from paranoid delusional disorder and schizophrenia, as well as Parkinson’s Disease.
In September 2015, Mr Scales was sectioned under the Mental Health Act and admitted to the Leeds and York Hospital.
Between December 27 and December 31, 2016, he was was granted permission to leave the hospital escorted.
On January 2, 2017 he was then granted un-escorted leave and he absconded.
He was later located in London by police officers, and he was taken to Gordon’s Hospital by police.
Arrangements were made to escort him back to Leeds by private ambulance.
But during the journey, the escort brought him the McDonald’s meal, which he choked on.
The inquest also heard that Mr Scales suffered from a similar choking incident on December 2, 2015 while on the ward of Leeds and York Hospital. He received backslaps to dislodge some food, which was causing him to choke.
Mr Scales' sister Pauline Howard, in a statement read out at the inquest, said: "I am very sad that David's life should have ended this way."
The inquest is due to conclude on Thursday.