A former physician-in-waiting to the British Royal family told an inquest yesterday that emergency room doctors at King Edward VII Memorial Hospital failed to carry out two life-saving procedures on a man suffocating to death.

Derek Enlander said physicians could have used a defibrillator to restart Norman Palmer's heart after he flatlined on April 12 last year and should have performed a procedure known as a tracheostomy to open his airway.

But his evidence was contradicted by one of the ER physicians who tried to save 57-year-old Mr. Palmer's life. Mustansir Malik told the Magistrates' Court hearing that a more appropriate procedure called a cricothyroidotomy — cutting a hole in the neck to create an emergency breathing passage — was conducted but it was already too late.

Dr. Malik described how he was in the doctors' office at KEMH when he heard Mr. Palmer making a high pitched noise — known medically as a "stridor" — in the resuscitation room and went to help as the sound indicated a "very dire prognosis".

"He was blue, meaning a dire lack of oxygen," he told the inquest. "As far as I was concerned, he was towards the end of his life. From hearing the stridor, that pitch and the noise that we could hear meant this was not going to go well."

He told Coroner Khamisi Tokunbo a tracheostomy had "no place" in an ER setting and would only be done if a patient was stable and had adequate oxygen.

Instead, a cricothyroidotomy was carried out, which he said was very difficult because of a lot of scarring in Mr. Palmer's throat, who had a 40-year-old gunshot injury. He said one of his colleagues had to make a larger than normal incision.

Asked by Jeffrey Elkinson, lawyer for the family, why neither relatives nor a pathologist who carried out an autopsy on Mr. Palmer found evidence that a cut had been made, Dr. Malik replied: "They probably made a mistake because there was a scar and we got in. There is no question."

He told the court that when Mr. Palmer's heart stopped he was not defibrillated because that didn't work when a person displayed "asystole" i.e. had flatlined.

At one point during his evidence Dr. Malik, called as a witness by Bermuda Hospitals Board (BHB), indicated to Mr. Palmer's family sitting in court and said: "I'm getting some awful stares here."

Mr. Tokunbo told him not to be concerned with that. "It's me that you are giving evidence to," he said.

Dr. Enlander, called as an expert witness by the family, told the inquest he had used a defibrillator to resuscitate patients who had flatlined. "I believe that a defibrillator can be used in asystole," he said.

The physician, a specialist at Mount Sinai Medical School in New York, also told the hearing that a tracheostomy was the "preferred" technique in an emergency situation and was a common and "very fast" procedure.

"I am surprised one was not performed sooner on this patient as, given that it is accepted that he had an obstruction in his throat, this may have saved his life," he said.

Mr. Palmer, a Brit who ran his own excavating business in Bermuda, was found by a UK pathologist to have many of his organs and tissues missing after his body was flown to Britain for cremation and a second post-mortem was conducted.

His sister Heather Carberry, of Somerset, England, told the first day of the inquest on Thursday that the family were never informed that the first autopsy was being held and were stunned to learn his body parts were missing. "This is like a horror movie about some witchcraft or evil practice," she said.

Yesterday, during a tense cross-examination by BHB's lawyer Allan Doughty, she cried as she described watching her brother dying. "I saw my brother gasping for air until he couldn't breathe anymore," she said.

Mr. Doughty read an extract from the final report of British pathologist Ed Cooper in which he said he agreed with the findings of the pathologist in Bermuda, Kared James.

He gave the cause of death as respiratory failure with complicating excessive fibrous tissue in the larynx and asthma-related mucus plugging of the airway in a patient with a previous gunshot trauma to the neck.

"Would you agree that the UK pathologist actually concurred with the findings of the Bermuda pathologist?" he asked. "No," replied Ms Carberry.

The hearing continues on Monday.