A teenage motorcyclist succumbs to injuries after a road crash. A tourist drowns on a day out at the beach. A worker dies while at their place of employment.

Each of these sudden deaths — and plenty of others in recent decades — prompt an obvious question: how did they happen?

In many jurisdictions, public inquests would be held to determine the answer. In some cases, if evidence showed that something could be done to prevent future fatalities, a report containing recommendations would be released by the coroner.

In Bermuda, it’s a different story.

The island continues to lag far behind other countries in holding public inquests into unexpected and unusual deaths, largely dealing with such matters behind closed doors.

In the past ten years, only four public inquests appear to have been opened. During the same period, there were 981 sudden deaths reported to and reviewed by the senior magistrate and coroner, according to the latest figures released by the judiciary.

In other words, only about 0.4 per cent of deaths reported to the coroner proceeded to a public inquest. For comparison, in England and Wales in 2024, 21 per cent of deaths reported to coroners resulted in an inquest.

In the Cayman Islands, the Coroner’s Court sits every four to six months for about a week. There were 15 inquests listed for its most recent sitting this month.

Opacity was not always the norm in Bermuda. Before 1999, when the Coroners Act was amended, the public were kept less in the dark.

Journalist Meredith Ebbin recalls: “Inquests for cases of accidental or suspicious deaths were held routinely during my years as a reporter in the Eighties and Nineties, and prior to that.

“Recommendations were also made. I thought the whole point of inquests is for accidental or suspicious deaths, such as road traffic and workplace fatalities and suicides, to be examined in a public hearing, the causes determined and recommendations made to prevent such deaths in future.”

On the rare occasions a public inquest is held here, it is often not until many years after the sudden death. The two most recent inquests, in 2023 and 2024, were for deaths in 2015 and 2018 respectively.

Do the lack of public hearings and the delays matter?

Could Bermuda’s inquests system be improved to benefit grieving families and help to prevent future deaths?

Lynn Spencer, who successfully pushed for an inquest into the death of her 25-year-old son, Chris, believes it could.

She said public inquests should “absolutely” be held in many more cases than at present.

“Everybody has the right to have an inquest, just to see if there is any way of trying to correct things,” she told The Royal Gazette.

Chris, 25, a former Gazette reporter, was a heroin addict who died in October 2012 after collapsing at home.

Ms Spencer’s lawyer, Saul Froomkin, was able to ask questions at the 2015 inquest into his death, including why EMTs did not give him Narcan, or Naloxone, a life-saving drug used to reverse heroin overdoses.

Juan Wolffe, who was senior magistrate and coroner, ruled that the use of Narcan in Mr Spencer’s case “was unnecessary and … in any event … would have been ineffective”, but recommended to the Bermuda Hospitals Board that it consider whether the drug could be administered via a nasal spray and whether EMTs could be trained to use it without a doctor’s permission.

The BHB changed its processes in response to the coroner’s report.

Ms Spencer said: “The benefit that the inquest had was that the ambulances now carry Narcan. That’s huge.”

She added: “It helped me to give Chris’s death a reason. Something good came out of his death.”

Mr Spencer was found by Mr Wolffe to have died from acute cardiopulmonary failure secondary to heroin abuse.

The coroner said at the time: “I think it’s an inquest that needed to be heard.

“It’s never going to give complete closure, but hopefully it answers some questions, and hopefully by having an inquest we can learn more about how to deal with those who fall prey to drug use.”

A recent report from the Bermuda Drug Information Network showed that in 2023 alone there were 63 suspicious deaths that required toxicology screenings, with drugs found to be present in 20 cases, drugs and alcohol in five cases, and alcohol in nine cases. The statistics are similar for other years.

Yet in the decade since Mr Wolffe made his remarks, there has not been another public inquest into a drug-related death.

Nor have there been any public inquests in the past ten years into the more than 100 road deaths, 20-plus drownings or several workplace fatalities that have happened during that period.

The Bermuda Road Safety Council said last year that it was in favour of holding public inquests to determine the causes of road deaths and potentially improve safety, but there has been no indication of plans to do so by senior magistrate and coroner Maxanne Anderson.

Seven people died owing to road crashes in 2024 and there have been five deaths this year, with the family of the most recent victim — 16-year-old motorcyclist Josh Frias — calling for changes to the stretch of road where he crashed.

A public inquest could look at all the circumstances of his death and consider whether improvements to the road should be made.

Like road deaths, workplace fatalities are a category of sudden death that often result in public inquests in other countries, followed by safety recommendations. In Bermuda, information tends to stay under wraps unless there are legal proceedings in court.

The Government’s Environmental Health Unit, in response to questions, shared that there were “legal proceedings in progress” regarding a 2023 workplace accident and there was potentially a workplace fatality this year “but investigation and coroner’s report [is] still under way”.

The unit said that under Section 19 of the Occupational Safety & Health Act 1982, information collected by occupational safety and health officers about workplace deaths was confidential.

Sergeant Lyndon Raynor, the coroner’s officer, confirmed that the Occupational and Health Unit was still inquiring into the death of father of three Thomas Lauwaske Jones, 55, after an industrial accident at the Fairmont Southampton hotel in April. He said the coroner was awaiting submission of a file.

Regarding the death of elevator engineer Robert Vaughan after an industrial accident at Seon Place in June 2022, Sergeant Raynor cited Section 9 of the Coroners Act, which allows the coroner to dispense with the need for an inquest after a post-mortem.

Of the four inquests that have taken place in the past decade, two were required to be held by law because the deceased — Wendell Baxter and Kevin Butterfield — were prisoners at Westgate.

The other two were the 2015 hearing into Mr Spencer’s death and a 2018 hearing into the death of American teenager Mark Dombroski.

Families have told the Gazette that private inquests are sometimes held, but no information is released publicly about these.

Keetha Lowe, whose daughter-in-law, Latifa Maybury, 30, died of colorectal cancer at King Edward VII Memorial Hospital in 2013, leaving behind a six-month-old son, said Bermuda’s lack of public inquests should be of concern to everyone in the community.

“The repercussions of this go deeper than you can possibly imagine,” she said.

“When an individual or family experiences trauma resulting from tragic death, the recovery time is impossible to predict.

“Most never recover enough to push for an inquest. Those who do can only hope that the process will be transparent and just.”

Ms Lowe’s son and Latifa’s widower, Kemar Maybury, successfully sued the BHB for medical negligence, winning $1.9 million in damages in 2020 because his wife’s cancerous tumour was missed by an emergency room doctor.

Ms Lowe said the family were “not offered the option of an inquest for Latifa”, but would have welcomed one.

She suggested there were “barriers” for families and others seeking answers about sudden deaths that were attributable to “Bermuda's culture of silence and fear of consequences”.

Ms Lowe said: “We live in a society that has a tendency to complain in corners about covert and overt injustices, yet self-paralyse at the very thought of evoking systemic and legislative change.

“This has been the case regardless of the leadership of the day. Thus, progressive change and betterment is a slow process, particularly where revised legislation and policy apply.”

The last public inquest in Bermuda involving alleged medical negligence concerned the 2008 death of Norman Palmer, 57, at KEMH.

The verdict, of death by natural causes contributed to by self-neglect, was later criticised by a coroner in England, where a second inquest was held after Mr Palmer’s body was repatriated to his home country.

In 2013, the hospitals board tried to stop an inquest being held about the 2002 death at KEMH of Hubert “Hubie” Brown, who was given a transfusion of the wrong blood type.

The board filed a lawsuit against the senior magistrate and coroner, a post held at the time by Archibald Warner, after he indicated that he would open an inquest into the circumstances of Mr Brown’s death, more than an decade after it occurred.

The board argued in its civil complaint that the 1999 amendment to the Coroners Act led to “complete ambiguity” and he had no jurisdiction to open an inquest into the death.

Deputy Solicitor-General Shakira Dill, for the coroner, explained to the Supreme Court that the legislation was broad, not vague, and the amendment simply gave the coroner the discretion to decide whether to hold an inquest, rather than him being required to do so for every case about which he was notified.

Puisne Judge Stephen Hellman ruled in the coroner’s favour, noting that before the 1999 amendment, the coroner would have been "under a duty“ to hold an inquest into Mr Brown’s death but could now decide himself.

Mr Justice Hellman wrote that “it has long been recognised that there is a public interest in the coroner holding an inquest where there is reasonable cause to suspect that a person has died a violent or unnatural death or a death of which the cause is unknown.

“These are matters which are rightly of concern to the community, and an inquest gives them the opportunity to understand what has happened and why.”

Despite the judgment, an inquest was never held into Mr Brown’s death.

The deceased bar owner’s brother-in-law, Danis Moore, told The Royal Gazette he was not sure why it did not happen.

“I guess they swept it all under the rug,” he alleged.

Mr Moore said the value of an inquest would have been to try to ensure the same mistake involving a blood transfusion did not happen again.

“It’s done and gone now, but it should have been held,” he added.

A BHB spokeswoman said there was “full disclosure with the family of the events relating to Mr Brown's tragic death”.

“A death certificate was signed by the coroner in 2008 and BHB settled with the family in 2010,” she added.

“This was all prior to the judicial review, in which it was established that the coroner could hold an inquiry.

“Such inquiries are the jurisdiction of the coroner, so BHB has no influence on if or when the coroner proceeds.”

The spokeswoman explained that the BHB refers cases to the coroner in line with its Reporting of Deaths policy, which lists various circumstances, including all operation room deaths within 24 hours of procedure, an unexpected death occurring during the post-anaesthetic recovery process and all deaths within 24 hours of admission.

“Inquiries are held at the coroner's discretion and we refer any questions relating to them to the coroner,” she added.

Mr Warner said last week he could not recall why the hearing into Mr Brown’s death did not take place. He retired as senior magistrate and coroner in October 2014, a few months after Mr Justice Hellman’s ruling.

However, the veteran lawyer offered some insight into why so few public inquests are held, explaining it was likely to be largely a “question of resources”.

“I don’t believe the Magistrates’ Court … is equipped to handle an inquest into every matter that’s classified as an unnatural death,” he said.

“And what’s the benefit of holding an inquest into every case?”

Mr Warner became senior magistrate and coroner soon after the 1999 amendment; he decided in 2007 to limit the number of public inquests, no longer holding them into deaths that were not contentious or did not involve public-interest issues.

“We used to have a number of inquests in Magistrates’ Court which took up enormous amounts of time, to the detriment of other cases,” he said.

“It’s quite an elaborate process to have an inquest.”

He said it made practical sense to deal with some sudden deaths without a full hearing — a view he shared with the Gazette in a 2013 interview.

“I still hold that view,” he said. “There’s no doubt that the purpose of an inquest is to ensure some transparency, but there is not every case that merits a full hearing.

“There is, in the system, more than one way of getting to the bottom of what happened.”

Mr Warner, who now works for Resolution Chambers, suggested that if there was a groundswell of public opinion in favour of more inquests, then consideration should be given to appointing a magistrate to deal solely with them.

“With the number of unnatural deaths, maybe it is time that an independent, separate magistrate is appointed.”

Chief Justice Larry Mussenden said in a statement that a change to the legislation was a matter for parliamentarians — joining Sergeant Raynor in referencing Section 9 of Coroners Act.

“In relation to the question about families wishing to have more inquests, we sympathise with the sentiment that having one may have helped them deal with their loss and better understand what happened,” he said.

“However, the coroner’s powers are limited to those provided for in the Act …”

Mr Justice Mussenden said Bermuda’s coroners were “engaged on an ongoing and regular basis to deal with deaths and inquests pursuant to the Act.

“The responsibility is a serious one which affects people already existing in a tragic and distressing period of their lives.

“The coroners and the administrative staff will continue to make every effort to deal with such matters on a timely basis.”

• If you have suffered the sudden death of a loved one and want to share your views or experiences regarding inquests, please e-mail sstrangeways@royalgazette.com