Police probe centred on claims following bungled transfer

His condition had deteriorated in an ambulance before his arrival at 1.40am and he developed severe breathing problems.

He was initially seen by a locum junior doctor on duty in A&E, who was apparently the most senior doctor on duty at that time.

An on-call junior doctor in the first year of training in anaesthetics was bleeped and gave Mr Cartwright drugs which appeared to settle his breathing.

Harrogate hospital does not have an out-of-hours service for ear, nose and throat problems and it was decided to transfer him to hospital in York following a telephone conversation with another junior doctor there.

The on-call consultant anaesthetist at Harrogate was called to see Mr Cartwright at 2.30am, when he appeared stable, was talking and did not have breathing problems, and agreed to the transfer plan, ensuring his junior colleague had emergency airway equipment in case of problems.

But their patient’s condition deteriorated about the time he was loaded into the ambulance 10 minutes later and he was no longer able to breathe.

Desperate efforts were made to revive him.

The junior anaesthetist and the specialist, who had been called back to A&E, were both unable to open his airway.

The consultant went on to perform an emergency operation on his neck although this was “briefly” delayed while a scalpel missing from the equipment pack for the procedure was found.

During this time Mr Cartwright stopped breathing for at least four minutes, causing significant brain damage.

He underwent emergency surgery to secure his breathing and doctors discovered his epiglottis at the entrance to his throat had become swollen, leaving him unable to breathe.

The hospital subsequently admitted breach in duty of care in the attempt to transfer Mr Cartwright when there were difficulties with his breathing.

North Yorkshire Police was called in shortly after he died and investigated the three doctors for manslaughter by gross negligence as well as the hospital for corporate manslaughter, interviewing the two anaesthetists under caution.

But nine months later the Crown Prosecution Service found there was insufficient evidence to proceed against the doctors or the hospital.

It said that the hospital’s transfer policy made it clear patients with a compromised airway or a potential for rapid deterioration and requirement for intervention were to be considered the “highest risk”.

But it said that it could not be proved “to the criminal standard that the decision to transfer was itself more than a minimal cause of his death”.

His family are now awaiting an inquest into his death.