death at the King Edward VII Memorial Hospital last January was "aggravated by a lack of professional care''.

The jurors agreed with pathologist Dr. John Winwick the actual cause of death was "cardiac arrest following anoxia associated with general anaesthesia following a tonsillectomy and adenoidectomy''.

Lawyer Mr. Julian Hall MP, representing Justin's parents Mr. and Mrs. Eddie Fisher, said he felt the verdict was "overwhelmingly correct''.

However, he added: "Whatever the verdict we could never be pleased with it when a young boy has died a tragic death that could have been prevented....If this inquest can help prevent a similar tragedy occurring, then I think it has been a success.'' Justin died after he stopped breathing in the recovery room and went into cardiac arrest following routine surgery last January 11. He was revived and kept on life support until January 18 when he was declared brain dead.

The jury of five men and seven women could have found a member of KEMH medical staff guilty of manslaughter if they believed beyond a reasonable doubt there was gross negligence or reckless disregard for a person's life.

Coroner the Wor. Will Francis, however, said he did not think there was enough evidence for such a finding but told the jury it was up to them.

It is the second time in a year that a coroner's jury has pinned part of the blame for a patient's death on the care they received while at KEMH.

Last September a jury hearing the inquest into Bermudian entertainer Ms Wendy Wilkinson's death found it was caused by a bike accident and was "aggravated by a lack of professional care'' at the hospital.

Bermuda Hospitals Board executive director Mr. Hume Martin said yesterday the verdict obviously concerned the hospital.

"Clearly the board has a responsibility to maintain the public's confidence in the hospital but we must not forget a lot of good things have happened here,'' he said.

Mr. Martin pointed out the board had not waited for the inquest to "respond to the tragic death'' and "take concrete measures to reduce the likelihood of such a death occurring again''.

Those measures included the purchase of pulse oximeters to better monitor patients in the recovery room, a firming up of recovery room rules and implementing several new policies procedures such as attempting to wake up patients every 15 minutes and calling the anaesthetist if they are cannot be roused.

Mr. Martin said the board had not yet decided if any disciplinary action will be taken against staff as a result of the inquest.

When contacted yesterday Mr. Fisher had no comment but said he and his wife would be making a statement to the media later this week.

He said he would say then whether they will take any further legal action as a result of the verdict.

Mr. Hall said the inquest had been such a traumatic experience for Mr. and Mrs. Fisher they had chosen not to be in court for the reading of the verdict -- though they were in court throughout the 14-day hearing.

Also in their verdict, which took just under two hours to reach, the jurors said the new policies and procedures in effect as a result of Justin's death and concerning the hand over and care of patients in the recovery room should "be strictly adhered to''.

And they recommended the recovery room be "sufficiently staffed'' so the nurse in charge can perform managerial instead of nursing duties.

The jury concluded its verdict by expressing condolences to the Fisher family for "their tragic loss''.

While summing up the evidence for the jury, Mr. Francis said what caused Justin to stop breathing and go into cardiac arrest was never established.

"The primary cause of his death is still in the realm of speculation,'' Mr.

Francis said. "All the doctors you've heard testimony from favour the theory first put forward by Dr. Tomos Huw Morris (Justin's anaesthetist) that of the head flexing and the tongue slipping back and causing an airway blockage. But it was never confirmed and in fact disputed by nurse Mrs. Diana Simons.'' Mrs. Simons said Justin was in the correct position and did not have his head bent when she found him not breathing last January 11.

During the 15-day hearing jurors heard from several KEMH employees that Dr.

Morris did not make close checks in the recovery room when he should have.

Senior nurse Mrs. June Belloquet said it was "never normal'' for a nurse to leave a patient unattended in the recovery room.

Justin's nurse Mrs. Pearlette Basden was suspended for a week for leaving him unattended to answer the telephone shortly after noon and go to the bathroom -- failing to conduct an important 12.10 vital signs check.

It was estimated Justin had stopped breathing for a minimum of five minutes and possibly as long as ten before Mrs. Simons, who took over from Mrs.

Basden, noticed and called for help sometime between 12.10 p.m. and 12.15 p.m.

Mrs. Basden admitted she was partially to blame for Justin's death, but said Dr. Morris was too because he did not make proper checks on him.

The nurse in charge of the recovery room that day Mrs. Doris Rawlins Matthews also admitted blame but only because she was burdened with having to do nursing duties as well as supervisory duties because of a staff shortage.