A UK coroner has questioned the findings of Bermuda officials who ruled that an Island resident was partly responsible for his own death by failing to follow medical advice.And at a second inquest into the death of Norman Palmer, East Somerset coroner Tony Williams said he believed many of Mr Palmer’s organs were removed while his body was still on the Island without his family’s consent, before it was sent back to the UK.Mr Palmer, 57, from Paget, died on April 12 2008 after complaining of breathing difficulties.The smoker and asthma sufferer had received a gunshot injury to his throat as a teenager and a year before his death began complaining of flu-like symptoms.But on April 6 2008 he visited the emergency room of King Edward VII Memorial Hospital after his symptoms deteriorated.Yesterday’s inquest heard that, although Mr Palmer was advised to see an on-call specialist, the self-employed construction worker declined, saying that he wanted to see his own consultant. But his family claims he was never told that his condition was life-threatening. His widow, Kathleen, said: “We were never advised as to the seriousness of Norman’s condition, nor the consequences his decision would have.”Three days after the hospital visit, on April 9, Mr Palmer visited his GP of 20 years, Dr Marion Hoefer, who said that his symptoms were asthma-related. The doctor prescribed her patient inhalers and booked him in for a scan on April 14, but on April 12 Mr Palmer began experiencing extreme breathing difficulties while at home with his wife.He decided to take a shower to ease his symptoms but his condition deteriorated “in a matter of minutes” and Mrs Palmer dialled 911 at 4.45pm, the inquest heard.Yesterday’s inquiry heard that the ambulance was delayed in reaching the Palmers’ home — just a two minute drive from the hospital — as the driver decided to reverse into the lane.“There was no sense of urgency,” Mrs Palmer said.“I was watching my husband slowly suffocating.”Mr Palmer arrived at KEMH at 5.07pm but died less than 20 minutes later.Mrs Palmer told the hearing that a request to visit her husband’s body in the KEMH morgue was denied.“I told her [a member of mortuary staff] I didn’t like the idea of him being alone down there,” she said.“I was told ‘I can assure you Mrs Palmer, he won’t be alone’.”A week later, Mr Palmer’s body was repatriated to his hometown of Yeovil in Somerset, where an autopsy discovered that many of Mr Palmer’s organs — including his brain, kidney and throat — were missing, even though Mr Palmer was not an organ donor and his family had not consented to the “mutilation”. The organs have never been traced and no explanation given, though a pathologist in Bermuda later offered to return Mr Palmer’s throat to British authorities, the hearing was told. An investigation by Bermuda police into the missing organs concluded that no crime had been committed.At a 2009 inquest in Bermuda, coroner Khamisi Tokunbo ruled that the self-employed construction worker was partly responsible for his own death as he did not heed the medical advice of an emergency room doctor when he first visited KEMH on April 6. A verdict of death by natural causes, contributed to by self-neglect, was recorded.An attempt by the family to have the verdict quashed was rejected by a Supreme Court judge in December, 2009.In a judicial review, Puisne Judge Geoffrey Bell ruled that Mr Palmer “clearly had the opportunity of doing something” after he was told by the emergency room doctor on April 6 that his condition was potentially life-threatening — but did not follow the advice given.But yesterday, Mr Williams rejected that opinion, stating that Mr Palmer had sought and was taking medical advice.“Self-neglect should only be recorded when there is a gross failure to obtain basic medical attention,” he said.“Mr Palmer was taking medical advice and following the advice of his doctor.”Referring to Mr Palmer’s missing organs, the coroner said that a lack of legislation in Bermuda meant that organs could be removed without permission.“I am satisfied that these body parts would have been removed in Bermuda because of the lack of the Human Tissue Act,” he said.“That meant the family were not advised of the removal and it only came to light as a result of further examination in this country.“I have to say it is not uncommon for bodies to be returned to this country with body parts missing.”Earlier, Mrs Palmer said her husband’s wish to be cremated had been denied because some of his organs had been removed, creating a potential need for further post-mortem examinations.“I still cannot come to terms with the fact that Norman is lying in a grave in the UK,” she told the hearing.“I cannot bring myself to think of what the pathologist did to Norman and how she brutally mutilated his body, it is beyond my comprehension.“We didn’t bury a human being, we only buried a shell of the person who was my companion and soul mate.“Someone needs to be held responsible for this despicable act. He need never have died.“I cry myself to sleep every night. I can never come to terms with the fact that Norman need not have died and what happened to his body after his death.”Following the inquest, Mr Palmer’s family said yesterday’s inquiry was a positive step but “doesn’t finish the story”.Mr Palmer’s sister, Heather Carberry, said: “None of us have any idea what happened to my brother’s organs. We still don’t know what happened.“All of his organs apart from one kidney are missing. They mutilated my brother. It is like a horror story. Where are his body parts? What did they do with them? What were they used for? Why didn’t they put them back?“I believe that if this had happened in the UK it wouldn’t have come to my brother even needing to call an ambulance. He would still be alive.”