Missing body parts victim Norman Palmer was partly responsible for his own death for failing to heed the medical advice of an emergency room doctor, a Coroner ruled yesterday.

Khamisi Tokunbo said the 57-year-old's refusal to be admitted to hospital on the advice of Ashfaq Syed six days before he died and his failure to return afterwards to King Edward VII Memorial Hospital for care amounted to "a gross failure to obtain medical attention".

But Mr. Palmer's sister Marion Bishop told The Royal Gazette last night that the family would challenge in court the verdict of death by natural causes contributed to by self-neglect.

"Never in my wildest dreams did I think they would say that it was Norm's self-neglect," said the Paget businesswoman. "I didn't expect them to go against the hospital but I didn't expect this."

Family lawyer Jeffrey Elkinson said Mr. Tokunbo had "misdirected himself as to the law" following a six-day inquest held last month and that a judicial review of the "self-neglect" element of the ruling would be sought.

He said Mr. Palmer followed the advice of his GP of 22 years, Monica Hoefert, who told him, according to evidence at the inquest from Mr. Palmer's widow Kathleen, that Dr. Syed's diagnosis of an upper airway obstruction was wrong and that his breathing difficulties were due to asthma.

"How could it be self-neglect to say that somebody had such faith in their doctor and followed their instructions that they caused their own death?" said Mr. Elkinson. "To me, it's open and shut. In fairness to the family, it shouldn't stick."

He added that the family would pursue legal action "sooner rather than later" against Dr. Hoefert, who did not take part in the inquest.

Mr. Palmer, an asthmatic with a 40-year-old gunshot wound in his neck, died on April 12 last year in the emergency room at KEMH after three doctors struggled in vain to save him.

He had earlier got into severe breathing difficulty at his home in Leafy Way, Paget, and was turning blue as his wife talked to the 911 operator.

The three main causes of death were respiratory failure, asthma-related mucous blocking his airways and excessive thickening of the tissue in his larynx.

Mr. Elkinson argued at the inquest for an outcome of natural causes contributed to by the neglect of Dr. Hoefert. Relatives also severely criticised the emergency care provided by KEMH.

David Hill, Bermuda Hospitals Board (BHB) CEO, said yesterday: "Bermuda Hospitals Board is pleased that the Coroner has completed his review of the facts and evidence from all parties and has come to the conclusion that the medical care provided by our emergency and medical professionals in no way contributed to the sad death of Mr Palmer."

Ms Bishop gasped as the ruling was delivered at Magistrates' Court and immediately left the courtroom. She said afterwards she was angry but had never expected the hospital to be held culpable.

"They are not going to blame the hospital, are they, or the ambulance people? There is only one hospital."

She claimed a series of "cock ups" — including Dr. Hoefert not doing enough to get her brother an immediate appointment with a throat specialist in the week before he died and the time it took an ambulance to reach him on April 12 — led to his death.

Mr. Palmer, a Brit with permanent residency here who ran his own excavating business, visited KEMH due to difficulty breathing and "rasping from the throat" on April 6.

He received treatment from Dr. Syed which made him feel better but he refused to see the throat specialist on duty, Wesley Miller, preferring to go home and make an appointment the next day with another specialist.

The inquest heard from Mr. Palmer's widow Kathleen, who was not present in court yesterday as she is in England, that she was unable to get him an appointment with his GP until April 9.

She said his GP's office, meanwhile, could not get him an appointment with the other specialist until the following week.

Mrs. Palmer claimed Dr. Hoefert was "really angry" with Dr. Syed's diagnosis, insisting Mr. Palmer's problems were asthma-related. She told the court her husband followed Dr. Hoefert's advice over Dr. Syed's. "He did not know Dr. Syed."

Mr. Tokunbo ruled that Dr. Hoefert, formerly a GP in St. George's but now working in Cayman, was not guilty of medical neglect in the legal context of an inquest because there was not a dependency between the deceased and herself.

"The deceased was not a person who could not provide for himself," he said, adding: "No doubt he was a person who trusted Dr. Hoefert and relied on her medical judgment."

Mr. Tokunbo added: "It should be noted that Dr. Hoefert neither testified in the proceedings, nor did she, in person or by counsel, examine any witnesses in the proceedings.

"This was so, even though she could have testified or exercised her right to examine witnesses."

The Coroner said the decision of Mr. Palmer - many of whose organs and tissues were found to be missing after his body was flown to England for cremation – not to be admitted to hospital on April 6 or to return to ER in the days that followed bore "a significant and unfortunate nexus to the outcome and events of April 12".

"The deceased's condition had deteriorated to a stage which rendered emergency medical treatment to save his life hopeless, given the history of a gunshot wound to his neck and the distorted anatomy/extensive fibrosis of the larynx," said Mr. Tokunbo. "On that day, time was of no consequence to the outcome."

He said the ambulance crew did all that was reasonably expected of them and the ER physicians gave appropriate care and treatment.

Allan Doughty, lawyer for BHB, said outside court: "What happened to Norman Palmer is an absolute tragedy but at the same time, after the result of a thorough and official investigation, we think the Coroner reached the correct conclusion."

Mr. Elkinson described Dr. Hoefert's decision not to be involved in the inquest as "extraordinary" and said the verdict left an "open wound" for the family.

"I think the one thing evident is that the family demand answers from Dr. Hoefert and clearly the only way they are going to get them is by pursuing their legal options," he said.

Dr. Hoefert did not return a call from this newspaper.