Coroner Khamisi Tokunbo has called for a review of the procedures surrounding the retention of human body parts following an inquest into the death of Norman Palmer.

And he said the authorities need to look at the adequacy of the ambulances at King Edward VII Memorial Hospital for Bermuda's narrow lanes, as well as the way emergency crews are dispatched and directed to addresses.

Mr. Tokunbo said the six-day hearing held last month into Mr. Palmer's death in the emergency room at King Edward VII Memorial Hospital brought to light issues beyond the scope of the inquest which needed to be addressed.

"In my judgment, such matters do not warrant comment beyond the obvious — that the relevant Bermudian authorities should review them and consider, what, if any, improvements can be made," he said.

Mr. Palmer, 57, died last April at KEMH after he started suffocating at his home in Leafy Way, Paget. His widow Kathleen described the response of the ambulance crew that attended their home as a "fiasco".

The inquest heard of the difficulty the ambulance driver had finding the address and manoeuvring the vehicle once he reached Leafy Way, which is just around the corner from KEMH.

And, in witness statements given to the coroner's officer but not heard at the inquest, Mr. Palmer's neighbours David Kerr and Bruce Law criticised the length of time it took to negotiate the ambulance in and out of Leafy Way.

In addition, many of Mr. Palmer's organs and tissues were found to be missing by a British pathologist after his body was flown to England for cremation.

The discovery horrified his family and hit the headlines here and abroad but was only touched on at the inquest, which is limited to determining how, when and where a person died.

Mr. Tokunbo found no fault with the ambulance crew or the emergency room team who dealt with Mr. Palmer. He said: "While at the deceased's residence, the EMTs (emergency medical technicians) did all that was reasonably expected of them in the circumstances by way of treatment and transport."

He added: "The emergency care and treatment that the deceased received in the emergency room on April 12, 2008, was the appropriate care and treatment."

But his report listed three concerns involving ambulances which he said needed to be looked at:

• The means by which ambulance crews are assisted in identifying and locating destinations around Bermuda to which they are dispatched;

• The manoeuvrability of the current fleet of ambulances in and around Bermuda's public and private roads;

• The communications between 911 dispatchers and responders.

A fourth concern was that the authorities should consider whether there is "the need for written authority for the retention of human organs for further examination following an autopsy".

The inquest heard that once KEMH's chief pathologist Kered James had permission from the Senior Coroner to carry out an autopsy on Mr. Palmer's body, she did not need any other permission to keep parts for further examination.

She told the hearing she kept only his larynx and thyroid to help determine the cause of death and put the rest of his organs in a bag to be placed with the body.

The larynx and thyroid were returned to the family but the whereabouts of other parts — including a kidney, two-thirds of his brain, his spleen and stomach — is still unknown.

Sergeant Adrian Cook, the coroner's officer, raised the issue of stricter regulations after he investigated the disappearance of the body parts.

His report, while finding no evidence of wrongdoing on the Island, recommended that Bermuda consider introducing the need for permission for retaining body parts and disclosed that KEMH had already "tightened up some of their practices and policies in the aftermath of this incident".

David Hill, CEO of Bermuda Hospitals Board, responded to the Coroner's recommendations yesterday, revealing that three smaller ambulances had already been ordered for the KEMH fleet.

"As our goal is constant improvement at BHB, the process improvements suggested by the Coroner will be carefully considered as part of our ongoing development of the emergency service," he said.

"We have an excellent working relationship with our on-Island emergency partners and will continue to work closely with them."

He added: "It is reassuring that none of the areas highlighted were found to be contributing factors in Mr Palmer's death."

He said BHB always sought to improve its services and had, unrelated to this case, been working with Massachusetts-based Partners Healthcare System to undertake reviews of the emergency services, as well as the potential of a remote training lab and the possibility of having paramedics here.

"We regularly make administrative improvements that deliver greater efficiencies and improved communications as a matter of course of business," said Mr. Hill. "We will continue working with our emergency partners to improve the emergency service for Bermuda."

Mr. Hill said BHB would work closely with the Ministry of Health and Coroner's office to review the "key suggestion" regarding written consent for body parts, as it would require a legislative change.

Mr. Tokunbo ruled that Mr. Palmer died of natural causes contributed to by self neglect because he did not follow the advice of an emergency room doctor a week before his death.

Mr. Hill said: "It was important that the full facts were made available to the community through this independent review. However, we have never lost sight of the fact that at the heart of this case is the death of a loved one and we continue to extend our sympathies to the family."

BHB chairman Herman Tucker said: "This has been a thorough, independent and transparent process and we are satisfied that the right conclusion has been made.

"On behalf of Bermuda Hospitals Board, I would like to recognise BHB staff members in emergency and pathology. This has been a difficult time for them and their families and we thank them for continuing to provide a professional and dedicated service to the people of Bermuda."