The organs of a British man who died in Bermuda were removed without the consent or knowledge of his family - and have never been found, an inquest has heard.
Norman Palmer, 57, died in a hospital on the island after suffering respiratory problems.
When his body was repatriated to his home town of Yeovil in Somerset a week later, it emerged many of his organs - including his brain, kidney and throat - were missing.
Norman Palmer died in a hospital on the island after suffering respiratory problems
An inquest held in Wells in Somerset heard Mr Palmer, who moved to Bermuda 30 years ago, was not an organ donor and his family were not informed before or after 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.
Mr Palmer died at Bermuda's King Edward VII Memorial Hospital on April 12 2008 following a long-standing respiratory problem, caused by a combination of asthma and an old shotgun wound.
His wife Kathleen Palmer told East Somerset Coroner's Court her husband had been denied his final wish of a cremation thanks to the removal of his organs, which meant there was a potential need for further post-mortem examinations.
Mrs Palmer told the hearing: "I still cannot come to terms with the fact that Norman is lying in a grave in the UK.
"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."
The inquest heard Mr Palmer was 16 he suffered a shotgun wound when the weapon he was carrying accidentally discharged.
He received lifesaving treatment but later developed fibrosis on the soft tissue, which led to the narrowing to his airway over the years.
The long-term smoker, who suffered from asthma, began complaining of flu-like symptoms in 2007 and was treated by his GP of 20 years, Dr Marion Hoefert.
On April 6 2008, he was admitted to hospital and was diagnosed as having an obstruction of his airway by Dr Ashfaq Syed.
He advised Mr Palmer to see on-call specialist Dr Wesley Millar but Mr Palmer refused, as he wanted to see his own consultant, the inquest heard.
Mrs Palmer said: "We were never advised as to the seriousness of Norman's condition, nor the consequences his decision would have."
Three days later, on April 9, Mr Palmer visited his GP, who insisted his breathing difficulties were "asthma-related" and prescribed more inhalers for treatment.
Mr Palmer followed Dr Hoefert's advice and planned to attend a scan she booked 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 help but rapidly deteriorated "in a matter of minutes" and Mrs Palmer dialled 911 at 4.45pm.
The court was told 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 the hospital at 5.07pm and "in severe respiratory distress". He went into cardiac arrest and died at 5.25pm.
Mrs Palmer later returned to the hospital to visit her husband in the morgue but her request was refused.
"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 post-mortem examination in Bermuda found the cause of death was respiratory failure and Mr Palmer's body was flown back to Britain on April 20 2008.
But a second post-mortem examination carried out by a British pathologist found Mr Palmer had been repatriated with most of his organs missing.
Dr Ed Cooper, a pathologist at Yeovil District Hospital, noted Mr Palmer's kidney, spleen, brain, throat, thyroid, prostate, bladder, small and large intestine had been removed.
He recorded the cause of death as respiratory failure caused by asthma related mucus plugging on the bronchi and laryngeal fibrosis.
At an inquest in Bermuda, coroner Khamisi Tokunbo recorded that Mr Palmer died of natural causes, as a result of self-neglect.
Mr Palmer's family contested the finding and appealed to the country's Supreme Court, who upheld it.
But East Somerset Coroner Tony Williams questioned the original finding as he recorded a narrative conclusion.
"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."
Mr Williams said he was unable to include the fact of Mr Palmer's missing organs in his formal conclusion.
But he added: "I am satisfied that these body parts would have been removed in Bermuda because of the lack of the Human Tissue Act.
"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."
Speaking after the inquest, Mr Palmer's family said the inquest in Britain was a positive step but "doesn't finish the story".
Heather Carberry, sister of Mr Palmer, 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."