SYSTEMIC failures at a general hospital contributed to the death of a man who had been admitted suffering from a sore throat, an inquest has heard.

Coroner Michael Oakley said HGV driver Tony Cartwright, of Terrington, North Yorkshire, suffered a severe brain injury after medical staff at Harrogate District Hospital misunderstood what specialist colleagues would be available to treat him there.

The hearing at County Hall, Northallerton, was told Mr Cartwright had been suffering a sore throat for a fortnight in June 2008 and after experiencing breathing issues while parked overnight on a farm near Ripon, was taken to the hospital.

Doctors said the 39-year-old's condition stabilised after he arrived at the hospital and they decided to transfer him to York Hospital as they did not know an ear, nose and throat consultant was available to travel to the Harrogate site.

While Mr Cartwright was suffering acute epiglottitis, a condition regarded as a medical emergency in which patients should not be transferred as it can cause airways to become blocked, medics at the hospital believed he could be suffering from a fishbone being stuck in his throat.

Professor Robert Aitkenhead said while there were risks over whatever course of action the medics had taken, it was an "amazing coincidence" that Mr Cartwright had stopped breathing while being put on an ambulance ahead of a planned transfer to York.

He said it took more than six minutes for doctors to restore Mr Cartwright's airways, but if the patient had remained in the hospital it would have taken several minutes less.

Mr Cartwright died 33 days later, as a result of the brain injury caused by the length of time his airways were blocked, which could have been averted if he had not been moved on to the ambulance.

The hearing was told the day after the incident, Dr George Priestley, a consultant anaethetist at York Hospital, wrote an email to colleagues in which he stated "disastrous transfers from Harrogate are a frequently recurring theme".

David Scullion, Harrogate and District Hospitals NHS Trust's medical director, said Dr Priestley's allegations were "baseless and unfounded" and said information about consultant cover had been available to staff.

He apologised to Mr Cartwright's widow, Debra, for her husband's treatment.

Recording a narrative verdict, Mr Oakley said had better information being provided to medical staff, the events that occurred need not have happened.

He added the erroneous decision to transfer Mr Cartwright had played a key role in his death.