Lawyer Liz Christopher has called for inquests to be given more teeth after the hearing on the death of Gladys Smith, who was allegedly left in a scalding hospital bath, failed to suggest improvements to the system.

Last week magistrate Ed King gave a ruling of death by misadventure for the 81-year-old pensioner who suffered a heart attack and first degree burns to her feet.

She died shortly after being found in a boiling hot bath in March, 2002 at King Edward VII Memorial Hospital.

Mr. King stressed throughout the inquest he was not there to apportion blame and that he could only inquire into who the deceased was, how when and where they met their death.

But Ms Christopher said such a narrow definition failed to suggest ways to stop such tragic events re-occurring by making recommendations for improvements.

During the inquest Ms Christopher, who represented orderly Laurie Furbert who placed Mrs. Smith in the bath, was barred from asking certain questions by Mr. King. She questioned why have an inquest into Mrs. Smith's death was when it had revealed so little. She later told The Royal Gazette: “We all know where she died.

“I would have wanted to know what the actual policies were in respect to treatment of the patients and I wanted to know more about what happened with the water temperature for when it went cold and when it went back to hot.

“Is there any mechanism to communicate that throughout the hospital effectively? What is the role of the orderly, does the orderly follow charts - who's responsible for looking at the charts?”

Coroner King summed up the facts after the case before giving his verdict of death by misadventure.

He said Mrs. Smith, who was categorised as a patient who needed assistance, had been taken to the tub in a chair lift after 9 a.m. and placed in the tub and left alone with the hot faucet running after she began to defecate.

She was then found alone in a steaming bathroom with her feet up to the ankles in hot water with the tap still running and the drain trapped by faeces.

Mr. King said the hot water had been running at less than lukewarm that morning but after 11 a.m. it was running hot but the patient was unable to reach the taps because of a barrier.

The autopsy had shown the feet had been “de-gloved” of skin while there was blistering on the left leg.

Mrs. Smith, of Railway Trail, Somerset Bridge had heart disease had only been admitted to King Edward VII Memorial Hospital a month before her death.

During the inquest orderly Furbert said he had been told to put Mrs. Smith in the bath by nurse Carmalita Francis but she had a medical condition which meant she was not supposed to be bathed in a tub.

However Mr. Furbert admitted he had left Mrs. Smith alone in the bath and gone for a break while nurse Francis was on her break. Nurse Francis remembered about Mrs. Smith only when a relative came calling.

The Royal Gazette understands Mr. Furbert was suspended for two weeks without pay but neither Ms Francis - the nurse - or any of the other staff on duty were disciplined.

An internal hospital report was compiled by the hospital's Administrative Risk Manger Aldwyn Savoury recommending policy changes but has yet to be released. Bermuda Hospitals Board Chairman Jonathan Brewin said last night: “The report that your are referring to is not public. We cannot release more information at this time.”

Mr. Savoury had told the inquest that Mr. Furbert had not followed the safety guidelines.

Ed Bailey, lawyer for the Smith family, said he had written to Bermuda Hospitals Board in the hope of settling a compensation claim out of court but had yet to get a response.

Ms Christopher said: “The recently conducted inquest might have helped if it had looked at what the policies and procedures were at the hospital in terms of the management of various areas and various. I am frustrated they did not get to the bottom of the issues.

“Prevention is better than cure and an inquest is a useful vehicle to see how that ounce of prevention could be exercise and, hopefully in future, it will.”

She said approaches to running inquests differed between magistrates Ed King and Will Francis with Mr. Francis tending to look for a wider examination of what transpired whereas Mr. King limits himself to a very narrow interpretation.

“I think the law allows magistrates to make recommendations. I think we need to regularise the position in respect to between how they are handled Mr. Francis and Mr. King.”

Powers of a Coroner's court were changed by an all-party agreement in 1999 after defence lawyers complained the Crown was using the method as a back door to help get a later conviction. Witnesses could be subpoenaed to give evidence in an inquest which implicated them in a later trial where they had a right not to give evidence.

The amendment removed the ability of a Coroner's jury to apportion blame.

It followed a case in the early 1990s where a coroner's jury found Mike Meredith was guilty for the murder of his wife but that was later quashed by the Supreme Court which said it breached the rules of natural justice and standards of proof were less exacting in inquests.

Mr. Meredith was later acquitted at a Supreme Court trial of the killing of Jacqueline Meredith who was found bludgeoned to death in her Smith's home.

Shadow Attorney General Trevor Moniz said an independent inquiry into the inquest system was a good idea to see if the system could be improved.

“This is obviously a terrible case and it's important we get to the bottom of it. You would think the hospital would have had an independent investigation into it with a report issued and the report should be made public.”

The case has also attracted the attention from seniors advocates who have called for tough laws on elderly abuse.