Zafar Siddique recorded a short form narrative conclusion into the death of Dorothy Dunn, 86, from Sedgley, who was taken to Russells Hall Hospital, in Dudley, on July 12, 2017, with a swollen tongue.
Mrs Dunn suffered a lack of blood flow to her brain and had a heart attack before sadly dying five days later.
The inquest at Black Country Coroner's Court, in Oldbury, was held after her family raised concerns about how the aftermath of her death was handled by the Dudley NHS Trust, which runs the hospital.
Recording his narrative conclusion, Mr Siddique said she was "administered to Russells Hall after she had developed a swelling of her tongue".
"It became clear her airway was blocked," he said.
An emergency procedure took place in the resuscitation department, but there was a "delay in finding the correct equipment, including a basic scalpel to do the procedure", said Mr Siddique.
He said her condition "deteriorated rapidly" and she died five days after being admitted to hospital.
Her medical cause of death was given as hypoxic brain injury, while contributing factors were angioedema, high blood pressure, diabetes and atrial fibrillation.
Mrs Dunn was known by her family as Dot. Her daughter described her as being "extremely generous, a wonder mother, and a strong and independent lady".
Recalling the family's concerns, Mr Siddique said these were about "the delay and failure in providing the necessary treatment" for Mrs Dunn.
He said the trust did not grade her death as "serious".
Following his conclusion, Mr Siddique said one area he would like reassurances from is the trust's "position about referrals to the coroner". He asked for a letter from the trust in 28 days.
Coverage of the inquest:
He said: "I would like reassurances from the chief executive and director that all death referrals, even those downgraded, should be referred to the coroner."
Addressing Mrs Dunn's family, he said: "I know this has been extremely difficult for you. I hope you have more answers than you did previously.
"I would like to take this opportunity to offer my deepest condolences."
The family was supported by law firm FBC Manby Bowdler.
After the inquest finished, Mrs Dunn’s granddaughter, Sarah George, said: "Something about the care provided never really felt right to us, which is why we requested the medical records and looked into it further.
"We are so glad that we did, and didn’t just ignore our gut instinct, as had we not pushed for answers we would never have known about the issues which occurred in the treatment provided.
"We hope that some good can come out of this and that the trust recognise it is important that open investigations are performed and families made aware of potential issues in treatment so that further distress can be avoided.
"We are also pleased that the coroner has raised his concerns about the reporting of potentially serious incidents to him in the future, and asked for the chief executive of the hospital trust to confirm that this is being done in writing."
In response to the story, Diane Wake, chief executive of the Dudley Group NHS Trust, said: "We would like to offer our sincere condolences to Dorothy Dunn’s family on her very sad death in 2017 while she was in our care.
"We fully accept the conclusion and findings of the coroner.
"The emergency situation that led Dorothy’s death in our resus department was exceptionally rare.
"Since 2017, we have changed our processes and improved governance including holding weekly assessments chaired by two executive directors and involving expert medical and surgical colleagues. We have also standardised difficult airway trolleys across the trust and introduced a system to fast bleep anaesthetists.
"These improvements prevented any similar situations arising.
"In August 2020, in line with national guideline, the Trust introduced the medical examiners service to independently scrutinise all deaths at the trust."