There were three different Directors of Public Prosecutions in as many years who took on responsibility for reviewing the circumstances of Gladys Smith?s death.

The fact that there was such a turnover in the lead position at the office of Public Prosecutions played some part in the four-year delay between the incident and anyone being charged in relation to the 81-year-old?s death, according to former DPP Kulandra Ratneser.

Chief Justice Richard Ground has strongly criticised the lengthy delays in bringing criminal charges after he ruled that two defendants who had worked at the hospital at the time should not now be tried because it would be impossible for them to receive a fair trial.

In a judgment he said delays bringing a prosecution case ? the defendants were not charged until April this year ? made it now virtually impossible for them to seek independent examinations of hospital equipment, seek witnesses or arrange an independent autopsy of the late Mrs. Smith.

Three DPPs have been in place since the incident in 2002 and that turnover must have played a part in the delays that ensued, according to former DPP Mr. Ratneser who replaced Khamisi Tokunbo as DPP in March 2003 and was himself replaced by Vinette Graham Allen in the second half of 2004.

He recalled there had been delays resulting from the problems between the KEMH and the Police investigation at the time and he had ordered the coroner?s inquest in 2003, which was then hit by adjournment arguments that ended up in the Supreme Court and were resolved more than a year later, by which time he was no longer DPP.

He said: ?When I became DPP I made a decision and actioned it quite quickly, and that was to have a coroner?s inquest. I think with the changes of DPPs, the delays were inevitable.?