Organs belonging to missing body parts victim Norman Palmer were kept for further examination by Bermuda's chief pathologist without written consent, an inquest heard yesterday.

Kered James told a hearing into 57-year-old Mr. Palmer's death that she got the verbal go-ahead to retain his larynx and thyroid after post-mortem from coroner's officer Adrian Cook, but had no written note of the permission.

She told Coroner Khamisi Tokunbo that she and her assistant placed "every other tissue and organ that was removed" from Mr. Palmer into a plastic bag that was put back into his body.

No formal inventory or checklist was kept of the parts which were put in the bag, explained Dr. James. But she added: "I witnessed every single organ going back into that bag. I do not leave the room until everything is cleared and it's all securely in the bag."

Mr. Palmer's family has claimed many of his organs and tissues were stolen after he died at the King Edward VII Memorial Hospital (KEMH) after getting into breathing difficulty on April 12 last year.

An English pathologist flagged up the fact that they had disappeared after his body was flown back to the UK, where he was originally from, for cremation.

Jeffrey Elkinson, the family's lawyer, asked Dr. James yesterday if she thought it was a "serious failure" not to have something in writing giving her authority to keep the larynx and thyroid.

She replied that though it may be different in other jurisdictions "here in Bermuda, I do not need written consent".

Dr. James, chief pathologist at KEMH, was giving evidence on the sixth and last day of the inquiry into how Mr. Palmer, of Leafy Way, Paget, died.

Mr. Elkinson asked why her initial post-mortem report failed to mention that Mr. Palmer, an asthmatic who ran his own excavating business, had shrapnel in his throat from a 40-year-old gunshot injury. She said she was aware of it but couldn't recall why it was omitted.

Dr. James told Magistrates' Court she took full responsibility for a "clerical error" which meant details of a surgical incision in Mr. Palmer's neck — known as a cricothyroidotomy — made by the emergency room doctors who tried to save his life were also left out of the document, which was marked as a final report.

Mr. Elkinson suggested the omission caused "havoc" for the English pathologist who later carried out another autopsy on the body.

And he said the errors in the report "sadly, in their own way, probably contributed most to the grief of the Palmer family", who believed the potentially life-saving procedure was not conducted.

The inquest earlier heard evidence about the alleged failure of Mr. Palmer's GP Monica Hoefert to try to get him an urgent appointment with a specialist after he attended KEMH's emergency room with breathing problems on April 6 and the response of the ambulance service on April 12.

Mr. Elkinson said yesterday if there was one consensus at the inquest it was that Mr. Palmer's death may have been avoided. He asked the Coroner to record a verdict of death by natural causes, contributed to by neglect.

Such a verdict, he said, was available if it was shown that there was a lack of care in terms of medical attention.

He said the evidence about Dr. Hoefert — who is no longer on the Island — remained undisputed because she had chosen not to give a statement or attend.

Mr. Elkinson said the hearing raised questions about the efficiency of the ambulance dispatch service, the suitability of the vehicles themselves and the shortcomings of the system used at KEMH to alert GPs after their patients visit ER.

Allan Doughty, for Bermuda Hospitals Board, said the verdict ought to be natural causes, contributed to by self-neglect.

He argued that Mr. Palmer "opted not to seek the fundamental medical care that he needed" by refusing to see an on-call ear, nose and throat specialist at KEMH on April 6 and not returning to ER in the days that followed.

Adjourning the hearing, Mr. Tokunbo noted: "It goes without saying that there are a number of issues that may be commented on or identified for improvement that have surfaced in this case."

He will record his verdict next month.

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