AS the family of missing organs victim Norman Palmer await the verdict of last month's unprecedented inquest, the Mid-Ocean News has learned of two key witness statements left out of courtroom proceedings that reveal an exceptionally slow and inept ambulance journey.

Statements made by two neighbours of Mr. Palmer to the Coroner's Court in early January of this year attest that the ambulance took up to seven minutes to complete a 15-second journey – and that far larger vehicles have manoeuvred the same area in far less time and with less difficulty.

Mr. Palmer died shortly after being admitted to King Edward VII Memorial Hospital with breathing difficulties on April 12 last year. When his body was flown to the UK for cremation, a UK pathologist found that many of his body parts and organs were missing, prompting both British coroner Tony Williams and Bermuda coroner's officer at the time, Sergeant Adrian Cook, to call for an investigation.

Last month's inquest, the first of its kind in Bermuda, heard that it took over eight minutes for an ambulance to reach Mr. Palmer's home on Leafy Way, just off Tee Street in Paget, in very close proximity to the hospital.

Mr. Palmer's widow Kathleen told Coroner Khamisi Tokunbo that the ambulance's dispatch and subsequent slow struggle to reach Mr. Palmer was a "fiasco", with "no sense of urgency" and driven by an "unpleasant" EMT.

Hospital head of emergency services Dr. Edward Schultz admitted during the inquest that there were "problems with emergency medical dispatching" on the island that need remedying, but claimed that it was already too late to save Mr. Palmer by the time of dispatch as he was reportedly turning blue at his home.

What the inquest did not hear, however, are the witness statements of two Leafy Way residents, who observed the ambulance's slow, clumsy approach towards Mr. Palmer's house, describing the journey as having being navigated with greater ease by far larger trucks.

One of the witnesses, from the vantage point of his home "directly adjacent" to Mr. Palmer's, described the ambulance's journey as the slowest he's seen in 14 years as a resident of Leafy Way.

"I have never seen any vehicle take as long as the ambulance did that day to manoeuvre onto or off of our property," he said.

"Over the past 14 years my wife and I have been improving our house by constructing a pool, adding a studio cottage and having another well drilled," he said.

"We have had in doing this construction vehicles of all sizes and descriptions traveling to and from our property along Leafy Way and our driveway. I have never seen anyone (including non- construction traffic) reverse down Leafy Way to get to Tee Street."

He added that vehicles "much larger" than the ambulance trying to reach Mr. Palmer had successfully navigated Leafy Way in the past.

"In particular I recall the well drilling truck from Atlantic [Water Development Ltd] / Hamish Burns which is probably the largest vehicle that has come to our property and is much larger than the ambulance," he said.

"I saw it drive in when it came to drill our well and it arrived much more quickly and easily than the ambulance did that day."

The same witness described the ambulance's laboured approach, which involved the driver making complicated manoeuvres and ending up "on a grassy bank".

When he tried to assist by pointing out an easier way to reach Mr. Palmer's house, the witness reports that the ambulance driver ignored him.

"I told him he could drive down to their residence going in forwards rather than reversing as going forwards would be easier and there was enough room down there to turn around," he said.

"The driver did not respond and continued to manoeuvre the vehicle."

Another witness, also a Leafy Way resident, described the ambulance driver's "difficulty reversing", and noted the extreme length of time it took for the ambulance carrying Mr. Palmer to reach Tee Street.

"As the ambulance reversed I walked down the lane to Tee Street in order to assist with stopping traffic if necessary upon his reaching Tee Street," he said.

"From my recollection it took him a long time to do this. My best estimate would be five to seven minutes. In my experience of driving down the lane going forwards that distance it normally takes fifteen seconds if you drive carefully."

The ambulance driver, Aleston Armstrong, defended himself to the coroner during last month's inquest, telling the hearing: "I done the best I could at the time."

He said he did not know where Leafy Way was, and relied on the 911 operator for direction.

The coroner's inquest verdict is expected to be given on February 26.

Sgt. Cook, who is still working on this case, was unable to comment as to why these two witness statements were not included in the hearings.