THE distraught family of Craig Archer may never fully know why he died in York Hospital after an inquest heard that a vital piece of equipment had gone missing.

York Coroner Donald Coverdale, recording an open verdict on the 21-year-old York printer, who died in May, 2001, said he would be pressing York NHS Trust to tighten up on procedures.

He said the trust's policy required it to preserve medical equipment when a post-mortem examination was required, and the loss of a three-way tap attached to a catheter into Craig's chest meant it had not been available for testing by experts.

The solicitor for Craig's parents ,Maureen and Keith Archer, said today that the distraught couple shared the coroner's concern about the loss of the equipment, which he said had prejudiced the investigation into Craig's death.

"They may never know whether this equipment was at fault and did or did not cause his death," said Stuart Hanley, of Langleys.

He revealed that his firm's investigations into the death would continue, and there was a possibility of civil action against the York trust.

Mr Coverdale apologised to Craig's family for the long delays in holding the inquest, which have been extensively reported in the Evening Press over the past 18 months.

He referred to the "dreadful delay" in getting the results of equipment tests from the Medicines and Health Care Products Regulatory Agency (MHRA), but said he must bear the ultimate responsibility.

The six-hour inquest at New Earswick Folk Hall yesterday heard that Craig, of Lucas Avenue, Clifton, was being successfully treated in hospital for ulcerative colitis when he collapsed in the middle of the night.

Nurses on Ward 33 heard a loud bang from his room, and found him lying on the floor, with a drip stand pulled down on top of him.

The catheter into his chest, which because of the three-way tap was able to simultaneously give him nutrition and antibiotics intravenously, had become detached.

Medical staff battled to resuscitate him for 45 minutes, but were unable to save him.

Pathologist Christine Bates said an examination of the heart revealed "frothy blood", indicating that there had been an air embolism, and there had been no evidence to support other possible causes of death such as allergic reaction or septicaemia.

Mr Coverdale said the cause of death had been an air embolism due to the catheter becoming detached.

There were a number of possible reasons why the catheter might have become detached, including a manufacturing defect, the equipment becoming snagged on bedclothes, poor insertion and Craig fainting or stumbling, or Craig himself detaching the equipment, but there was no evidence that any of these had happened.

Earlier, Craig's sister, Tracey, had stormed out of the inquest in disgust when the lawyer for a medical equipment manufacturer suggested it was possible that Craig - described during the inquest as a "helpful and compliant" patient -might have disconnected the catheter.

Craig's mother, Maureen Archer, also cried out: "How dare you say that about my son?"

York Hospitals NHS Trust today extended its deepest sympathies to Craig's family, and said it welcomed the coroner's open verdict, which it believed was correct.

"The Trust complied with the correct protocol and procedures at the time of this tragic incident," said a spokesman. "The Trust has a process in place to regularly review all policies and any recommendations from the coroner will be used to inform this process."

He said no criticism had been raised against the nursing staff.

Updated: 14:14 Wednesday, March 17, 2004