accident victim but has declared the man died of head injuries.

He called it "bewildering'' that doctors did not consider that Howard Berkeley had serious internal head injuries and a medical condition which made treatment more difficult.

And Mr. Warner said it "seems wholly inadequate'' that a CAT scan was not ordered on Mr. Berkeley, who died on August 11, 1996 at KEMH after he had originally been diagnosed with a broken leg and facial injuries.

Mr. Berkeley, 50, of Serpentine Road, had rammed into a parked car on Cavendish Road, Pembroke on August 6 and suffered massive brain haemorraging three days later.

The inquest was held last month in which a series of doctors took the stand.

None of the medical witnesses or their lawyers were present for Friday's hearing.

The case was conducted by Police coroner's officer Sgt. Phil Taylor, while lawyer Juliana Jack and Saul Froomkin represented the Berkeley family.

Mr. Berkeley died of head injuries as a result of the crash, Mr. Warner found, but he stopped short of saying the man got "less than adequate'' care.

He explained the law is very narrowly defined for the type of verdict that Coroners can give, adding there must be a "clear and causal evidence of neglect of care'' for a patient to declare anyone at fault.

The inquest revolved around the original diagnosis particularly whether Doctor's took into account Mr. Berkeley's pre-existing medical condition of idiopathicthrombocytopaenia or ITCP in which the lack of sufficient red cells hampers blood clotting which heals wounds.

Alcohol abusers who have damaged their livers and people with liver injuries often have ITCP which makes medical treatment tricky and requires constant monitoring.

The inquest heard Mr. Berkeley was an alcoholic and drug abuser, but that medical records indicating this were not produced until late in his hospital stay.

Surgeon Terrance Elliott testified he was "misled with faulty information'' by emergency room staff of the ITCP condition and because of that he did not require the man to undergo a general surgical assessment.

Another doctor, Barbara Jones, said she knew of Mr. Berkeley's medical history and ITCP condition and felt during an evening shift of August 8 he had stabilised enough not to warrant a blood platelet infusion.

The court heard Mr. Berkeley's blood platelet count had dropped to 14,000 per millimetre of blood, whereas the normal count is between 150,00 and 400,00.

After the verdict, a Berkeley family spokeswoman said her family "has not made a decision yet'' on what further action it may take, and blasted the whole process which took three years to reach its climax.

"We just want to let families know that they have other recourses when it comes to the hospital, they can be a part of the coroner's hearing,'' she said. "We talked about it and we we didn't want it to happen the way it was going.'' She added: "We don't think he received the best care because of the type of person he was and his homelessness. But just because he was not living under his parents rules doesn't mean he was not loved.'' "They never called us. Nothing. His father found out in the supermarket when someone asked him about his son. That's how we found out after four days. He was forgotten down there. Why wait until he was pretty much brain dead until you call his family?'' During the inquest, investigating officer Donville Yarde said he had "difficulty'' in finding Mr. Berkeley's family and staffing difficulties within the service had delayed the inquest.

The woman added: "The diagnosis and treatment just seems to have been a process they were going through with him.'' "It came out in the evidence and you could see it from the way they acted that it was a revolving door of doctors handing him on to the next doctor.

They never reviewed his charts.''