A four-year-old girl died after choking on a piece of Swiss roll at a Bristol nursery, a coroner's court was told.
The inquest at Flax Bourton heard Katie Stockham was born with a condition which made it difficult to swallow.
The nursery had a machine to suck food out of her throat, but it had not been needed for two years and had been taken away, the inquest heard.
An accidental death verdict was entered but the coroner said it was unfortunate the machine had been removed.
The inquest heard when Katie, from Brislington, Bristol, was younger she had to be fed through a tube, although her parents and nursery staff had been able to get her eating solid foods.
Five days before the accident her mother, Jeanette, had taken the suction machine away from the nursery because Katie was due to start at primary school in September.
Abacus Day Nursery worker Sarah Radnedge described how Katie had collapsed after choking on her tea. She said: "I was in the middle of handing out the cake when I noticed Katie was making a funny noise.
"I thought she was choking so I hit her on the back and she was sick. She appeared to recover so I gave her a tissue."
But when Ms Radnedge went to fetch another tissue the youngster fell to the ground.
"I realised she had collapsed, hit her on the back a few times and then started mouth-to-mouth."
"It was all quite sudden. She seemed fine one minute and then it happened," she told the inquest.
Katie was taken to Bristol Children's Hospital but was pronounced dead in the early hours of 1 September.
The inquest heard there were no suspicious circumstances and Ofsted had given the nursery a good report.
Recording a verdict of accidental death, coroner Paul Forrest said: "It is quite obvious that care had been taken in all respects to the care of this child at the nursery, including the use of the suction machine.
"It's just unfortunate that on this occasion things went horribly wrong and the child died as a result."
Neither Mrs Stockham nor her husband, Simon, were present at the inquest on Thursday.