Police in Devon are investigating the death of a hospital patient whose feeding tube was wrongly inserted into her lung instead of her stomach.
Muriel Elliott, 77, died in Plymouth's Derriford Hospital last September.
But an internal hospital investigation has been unable to identify the doctor who wrongly verified that the tube had been placed in the correct position.
Plymouth Hospitals Trust said it has held a full investigation and has shared the results with the coroner.
'Thorough investigation'
BBC Spotlight has seen a report prepared by Derriford Hospital's legal department in relation to the case.
According to the report Mrs Elliott had a stroke following heart bypass surgery and on 31 August 2006, a nurse inserted a nasal gastric tube before Mrs Elliott's transfer to the Acute Stroke Unit.
At 0030 BST a chest x-ray was performed and a nurse on the stroke unit asked for the cover Senior House Officer (SHO) to check the position of the feeding tube on the x-ray.
The SHO told her the tube was in the correct place but did not record his findings in the patient's notes.
A hospital log identified a doctor who had viewed Mrs Elliott's x-ray at 0328 BST, but it transpired that the doctor identified was not at the hospital that night.
That doctor had given his password to the cover SHO, a female doctor, but the stroke unit nurse said she was not the doctor who checked Mrs Elliott's x-ray, as it was checked by a man.
By 0730 BST the nurse began feeding Mrs Elliott through the tube and the report concluded that "despite a thorough investigation... it has not been possible to identify the doctor who verified the position of the nasal gastric tube".
Mrs Elliott died 13 days after the tube was wrongly inserted.
Brian Gerrish, Mrs Elliott's son-in-law, said: "This is absolutely incredible.
"If you take it to its conclusion we say Derriford does not know who the doctor was that made a clinical decision that resulted in a death and it's possible it could have been somebody who just walked in off the street, because they have no idea."
In a statement Plymouth Hospitals NHS Trust said: "We do have stringent policies and guidelines concerning patient confidentiality and the use of IT systems.
"We do expect all staff to work according to those policies and investigate any breach and take the appropriate disciplinary action."
Devon and Cornwall Police said the coroner had referred the case to them and inquiries by their major crime investigation team were at an early stage.
It is understood an inquest into Mrs Elliott's death will be held after the police investigation has been completed.
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