The death of a severely-disabled pupil who choked on a meatball was not due to staff negligence, a coroner has ruled.

Despite desperate efforts to save her life Isabel Pearce, 13, died the day after choking while eating lunch at Ridge View School in Tonbridge in January.

Today, senior coroner Roger Hatch concluded her death was tragic and unfortunate, but due to misadventure.

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Summing up the three-day inquest he said: "This is not a case of negligence in any shape of form. There is no evidence I have heard and considered which would justify such a conclusion.

"I am satisfied the treatment provided to her, firstly at the school and by the ambulance service was appropriate and carried out efficiently.

"It is unfortunate the meatball was something between 2cm and 2.5cm which my pathologist described as the ideal choking size. Unfortunately, through no fault of the school or staff this tragedy occurred.

"There is no doubt that Isabel required supervision when eating. The care of Isabel was satisfactory but there are bound to be times when she could not be watched while eating for 100 per cent of the time."

The inquest at Gravesend Old Town Hall heard a police investigation was launched in the aftermath of Isabel's death, but there was insufficient evidence to bring criminal charges.

Isabel, who was a former pupil at Oakley School in Tunbridge Wells, suffered from a rare genetic condition - Sotos syndrome - autism, global developmental delay, a visual impairment, scoliosis and had previously undergone a cleft palette correction and spinal surgery.

On Monday, the court was told the young pupil, who lived in Ide Hill, Sevenoaks, was eating lunch on a table with five pupils and two members of staff on January 16 when the tragic incident unfolded.

Moments after refusing to let teaching assistant, Jennifer Seymour, cut up her food she began choking and gagging.

School nurses, Deborah Marsden and Anita Beebe, were called to help and carried out back slaps and the Heimlich manoeuvre.

Miss Marsden said: "I saw Anita with Isabel who was on the floor and in some distress. Her face was pale, her lips were slightly blue she looked panicked."

"I was coughing to try and get Isabel to cough. I was removing anything that came out of her mouth. Some small bits of food and saliva came out, she seemed much better and her colour became pinker."

Isabel's parents, Jane and Anthony, heard their daughter stood up and was led towards a sensory room by Miss Beebee, but on the way she collapsed in the school's reception area.

Her face, lips and tip of her nose turned blue and her breathing became laboured.

Staff carried out further back slaps and abdominal thrusts and three minutes later called an ambulance.

Paramedics arrived and after two minutes on scene removed a whole meatball from Isabel's throat. She was taken to hospital, but died the following day.

The court was told teachers usually over-ride Isabel's wishes, even when eating, if they believe it is in the interest of her safety.

Isabel's parents questioned why she was allowed to eat an entire meatball when she never would have been served such a portion at home.

Mrs Pearce said: "I chose food for Isabel and she had suitable food prepared for her in terms of the size and shape of it. It always needed to be cut up like I was cutting it up for an 18-month-old so the risk was minimal.

"She didn't know the concept of it being too much on the fork especially if she was hungry."

One of Isabel's respite carers, Lucy-Ann Petto, told the court: "Isabel was most definitely not an independent eater. I do not believe she had the motor skills or dexterity to cut up and eat a meat ball herself."

The court heard there is an ongoing dispute between the parents and the school as to whether Isabel could eat independently.

In a care plan drafted by staff in 2014 it reads: "Isabel has school dinners and can independently feed herself." This was sent home to Mr and Mrs Pearce, but the parents claim they "slashed through" the incorrect parts and immediately send amendments back.

However, this document is missing and the school, which was rated outstanding by Ofsted following an inspection in June, claims it was never received.

Earlier this week Ridge View staff, including head teacher Jacqueline Tovey, were asked why an ambulance wasn't called when Isabel initially started choking.

Paramedic Robert Paris told the court choking incidents are treated as highest priority for ambulance crews and it's "very time critical for an ambulance to be called in such circumstances."

A spokesman for Kent County Council and the school said: “We note the Coroner’s verdict and in particular his comment that the school and its staff were not at fault in any way for this tragic incident.

"However, we know that nothing will lessen the pain for Isabel’s parents, and we extend our sympathy and condolences to them once again.”

Speaking after the inquest Isabel's family said they were outraged at the coroner's decision:

"We are shocked to hear the verdict essentially suggesting the school are completely exonerated by their behaviour on the day, suggesting a child with a mental age of 18 months was capable of determining for herself whether or not her lunch should be cut up or not.

"These were large meatballs and she had no mental ability to assess any kind of risk as to what danger these things possessed for her.

"We think the food should’ve been cut up as was common at home and with other carers and her previous school.

"Independent eating was a great goal for Isabel. By independent, it was meant she would pick the fork up to her mouth - not that she would independently assess the suitability of food stuffs before placing that in her mouth. She had no capability of doing that.

"Isabel was particularly happy at home. She liked to be with her family she enjoyed trips out with her carers, and enjoyed trips to Costa Coffee.

"She was a happy girl. Obviously she had severe health issues. She had been in Great Ormond Street very ill the previous year and we thought at one point we were going to lose her, but she pulled through.

"In January this year she was the healthiest she’d ever been and to go to school one day perfectly well and not come home is heartbreaking.

"We are taking advice as to what to do next."