Shadow Health Minister Louise Jackson has raised concerns about an alleged lack of hospital and ambulance equipment, which she claims could have saved the life of a 57-year-old man.

A UK Coroner's Post Mortem report into the death of Norman Palmer concurs with the Bermuda Coroner in that the cause of death was 'respiratory failure'.

Mr. Palmer, an asthmatic, died on April 12 at King Edward VII Memorial Hospital (KEMH). A British citizen, he requested his body be flown back to the UK to be cremated in the event of his death.

HM Coroner for East Somerset, Tony Williams, ordered a second post mortem in the UK, due to being dissatisfied with the Bermuda Coroner's cause of death as 'respiratory failure'.

It was during this examination that it was discovered most of Mr. Palmer's organs were missing.

These included: two-thirds of the brain including the brain stem; one kidney; the spleen; the "upper mediastinal structures" including the throat, and most of the small and large intestines.

The UK Coroner's Post Mortem report now suggests Mr. Palmer did not undergo a tracheostomy in an attempt to save his life, either in the ambulance or at the hospital.

Notes based on information from the Bermuda Coroner's Officer state Mr. Palmer "had been complaining of an obstruction in his throat for a couple of weeks".

An ambulance was called after he began struggling to breathe. The notes state: "ambulance to hospital, couldn't breath (SIC), told they would be doing tracheostomy but didn't do one".

Dr. E. J. Cooper, Consultant Histopathologist at Yeovil District Hospital in Somerset, then provides notes on 'With regards medications given in the emergency room in Bermuda', based on "various medical notes, X-rays, and other information relating to the medical history of Mr. Norman Palmer".

Dr. Cooper states: "No cricothyroidotomy pack available in the dept. Endotracheal intubation attempted – difficult, unable to intubate. Surgical airway attempted.

"Narrow trachea, scarring, distorted anatomy. Cricothyroidotomy. Unable to pass tracheal tube. Dr. Hammond tried to intubate. Unsuccessful. Pupils fixed, dilated. Cardiac monitor asystole. Declared dead 17.25 p.m. "

Dr. Cooper's summary says "the emergency staff (in A&E) attempted endotracheal tube intubation and later attempted a surgical airway.

"Both of these procedures were unsuccessful. The procedure would most likely have been an emergency cricothyroidotomy, which is a procedure to make a hole in the soft tissues of the neck to aid breathing or bypass any obstruction".

"This emergency 'hole' would not have been the same as making a tracheostomy hole which, from my own experience, is a more permanent and larger hole. I note from the funeral directors statement that at 'the base of the throat' was a 'trach hole'.

This is presumably the emergency cricothyroidotomy hole made by the emergency staff rather than a tracheostomy hole."

Dr. Cooper adds: "As far as I am aware, there is no comment made by the Bermuda pathologists about a hole in the neck at the time they undertook the first post mortem examination".

A tracheostomy, or tracheotomy, is an incision in the trachea (windpipe) to create a direct airway. It is performed to bypass an obstructed upper airway to deliver oxygen to the lungs, and is kept open with a hollow tracheostomy tube.

The family of Mr. Palmer, who lived in Leafy Way, Paget, are currently awaiting the results of an inquest into his death by the Bermuda Coroner. It allegedly took 20 minutes for the ambulance to get Mr. Palmer to Accident and Emergency, despite living just five minutes from the hospital, near Tee Street.

Friday, Ms Jackson said: "This man did not have a proper tracheostomy.

"I will be anxious to hear what the hospital has to say about the fact there was no tracheostomy pack, as stated in this report.

"If it is true there was no pack in the ambulance or in the hospital emergency department, then I don't know what's going on. There should have been a tracheostomy pack in the ambulance in the first place. Then the pack wasn't in the emergency room.

"Another question is, are the drivers and EMTs (Emergency Medical Technicians) in Bermuda trained to use one properly, as they are elsewhere in the world?"

Ms Jackson said: "If this person had been given a tracheostomy in the first place he would still be alive.

"First of all you had a 20 minute delay in getting to the hospital, and then for this to happen, he died under very strange circumstances."

A spokeswoman for the Bermuda Hospitals Board said yesterday: "BHB is unable to comment about this case, as there is an official Police investigation."