Coroner's concern over psychiatric care at Ysbyty Gwynedd
A coroner said she was concerned medication was not always quickly available for patients at an acute psychiatric unit at Bangor's Ysbyty Gwynedd hospital.
Coroner Nicola Jones told an inquest the lack of a 24-hour service seemed "at the very least inhumane".
She recorded a narrative verdict into the death of Audrey Jones, 52, from Holyhead, who died after being admitted to the psychiatric unit in March.
The hospital has made some changes.
The coroner is writing to the Betsi Cadwaladr University Health Board about the issue.
The inquest at Caernarfon heard the situation had improved but there were still three hours with no psychiatric doctor at the unit until 9am daily.
A narrative verdict was recorded on Miss Jones, described as psychotic and distressed, who died after being admitted to the psychiatric unit in March.
She had pushed a bread roll and tissue into her mouth, blocking her airway and leading to hypoxic brain damage.
The coroner said she was also concerned, but to a lesser extent, that the kitchen door was left open.
A Betsi Cadwaladr University Health Board spokesperson said: "The health board expresses its deepest condolences to the family of Audrey Jones.
"Although we are unable to comment extensively on this case, we are looking at what happened to make sure we improve our standards of care for patients."