A "frightening catalogue of blunders'' revealed in the inquest into four-year-old Justin Fisher's death has made legal action "inevitable,'' his parents Mr. and Mrs. Eddie Fisher announced yesterday.

They said the verdict of the Coroner's jury last month made it clear his death had been "preventable and resulted from negligence.'' The Fishers said they did not yet know exactly what action would be taken.

However, they called on Premier the Hon. Sir John Swan to "urgently and substantially'' review the Fatal Injuries (Actions for Damages) Act of 1949 which they said limits the amount that can be claimed in the event of a child's death to the "ridiculously low'' sum of $7,500.

"Any doctor, hospital, or nurse would be right to think this legislation gives full protection for incompetence and negligence,'' Mr. Fisher said.

They also called for the drawing up of a patient's Bill of Rights which they said was available in other countries and "desperately needed'' here.

The Fishers said a Bill of Rights would have alerted them to their right to employ private nursing care for Justin when he went into hospital last January for a routine tonsillectomy. He stopped breathing while in the recovery room, was revived but declared brain dead a week later.

Speaking at a press conference at their lawyer Mr. Julian Hall's office, they told of their sorrow, and their bitterness towards King Edward VII Memorial Hospital and its staff.

But they stressed: "We are not looking for a scapegoat. A number of people together with a hopelessly flawed hospital system were at fault.'' Mr. Fisher said he found it "easier to forgive the two nurses who stood up and admitted responsibility in Justin's death than the doctors who did not.'' Said Mr. Fisher: "What hurts the most is the fact Justin died alone, with the recovery room short-staffed and his mother not allowed in with him or given the option to hire a private duty nurse, the cost of which is $20 an hour ...'' He said he and his wife Jennifer at least hoped the inquest had contributed to the "beginnings of an improvement in the quality of care provided by Bermuda's medical and hospital professionals.'' "We know the Bermudian public will want to know whether we shall be taking legal action to recover some compensation for our grievous loss,'' Mr. Fisher added. "First and foremost, no amount of money can return our son to us ...

"Our legal advisers are continuing to study the case, however, and we cannot say at this stage whether, when, or against which individual(s) or institution(s) formal proceedings will be brought.'' The Fishers said the inquest into their son's death revealed: Failure to properly chart his vital signs during the operation.

An "excessive'' anaesthetic dose was given to him according to US hospitals they consulted.

He was left unattended in the recovery room against the standards and rules established for many years for all hospital recovery rooms.

Failure to perform a 12.10 p.m. check of his vital signs when merely looking at him then would have revealed he was pale and ashen.

Failure of Dr. Morris and recovery room nurses to notice he had not roused from anaesthesia some 30 minutes after the normal rousing time.