A wedding venue manager died after burning his throat on a hot fishcake that he was asked to sample by one of his own chefs.
Darren Hickey, 51, was leaving the wedding venue he managed in Chorley, Lancs, when he was asked to try a fishcake by one of the chefs.
The food burnt the back of his throat, causing his voice box to swell over the hours that followed, stopping him from breathing.
Dr Patrick Waugh, the pathologist who performed Mr Hickey's post-mortem, told Bolton Corner's Court the case was very rare and normally seen in people involved in house fires.
Dr Waugh said: "He would have had difficulty swallowing because of the pain.
"We normally see this scenario in people who are involved in house fires with inhalation of smoke which burns the airways or in industrial accidents with hot steam.
â€œThe patient can appear well, they will be talking to you, but then the swelling starts."
Acting senior coroner Alan Walsh heard how Mr Hickey had visited the Urgent Care ward at Chorley Hospital after complaining to his partner Neil Parkinson of pain in his throat on the afternoon of April 4.
He was seen by a practitioner in the ward who also contacted a specialist from the Ear, Nose and Throat unit at Preston Hospital.
However, the lack of burns to Mr Hickey's mouth and tongue meant they were unable to find the damage, which occurred further down his throat and required specialist equipment to be seen.
Mr Hickey was sent home with paracetamol and advised to return if his pain increased.
Returning to Ridgmont House, Mr Hickey went to his room to rest but at 9.45pm, Mr Parkinson heard his partner making noises and found him appearing to choke.
He told the inquest: "He shouted so I ran upstairs. He was stood up choking and coughing so I banged his back but then he slid forward onto the floor."
Paramedics treated Mr Hickey at the scene and rushed him to the Royal Bolton Hospital but he was pronounced dead in the early hours of April 5.
The inquest heard that the ambulance had been delayed by roughly five minutes due to a problem with the postcode but that this was unlikely to have contributed to Mr Hickey's death.
"He was enormously positive and enormously caring and gave to charity - he was a very generous, caring and compassionate man," Mr Walsh said.
Seven years previously Mr Hickey, a former maitre d', had suffered a stroke which had left him in hospital for 18 months, and some difficulty walking and speaking.
Despite this Mr Hickey channelled his energy into charity work and was handed the Inspirational Person of Courage Award by the Stroke Association.
The coroner said the case had raised questions about the care at Chorley Hospital's Urgent Care ward, which is run by GTD Healthcare.
Samuel Eaton, head of services for GTD in the region, and Matthew Gaunt, from NHS Greater Preston Clinical Commissioning Group, assured the coroner that a full review into the incident would be carried out.
Recording a verdict of accidental death, Mr Walsh said: "I believe there are enormous lessons to be learned.
"This was caused by eating a fishcake, very small and very hot but with catastrophic consequences. I find this an immense tragedy."