The brother of a woman who died 14 years ago following a routine kidney stone operation has branded a third inquest into her death a "whitewash" and a "stitch-up".
Bernard Bloom said he had spent more than £3million in legal fees trying to uncover the truth about how and why his sister, Carmel, died in 2002.
The 54-year-old passed away after a "lack of monitoring and communication" at the former BUPA-run Roding Hospital in Ilford, coroner Karon Monaghan ruled on Monday.
Ms Bloom, from Ilford, Essex, had been admitted on August 27, 2002 with severe pain. She subsequently had an operation to remove a kidney stone but was transferred to Whipps Cross Hospital in the early hours of August 29.
En route she slipped into a coma, suffered a heart attack and brain damage before dying a week later from multiple organ failure.
Urological surgeon Dr John Hines and anaesthetist Dr Paul Timmis were cleared of misconduct by the General Medical Council in 2010. A panel ruled they made an "isolated error of judgment" but found they both had unblemished records and were "unlikely to repeat the error".
The GMC found the doctors' actions were "inappropriate'" and "not in the patient's best interests", but said they did not amount to misconduct.
The point was reinforced by this week's verdict at the Royal Courts of Justice. Ms Monaghan ruled against Mr Bloom's assertion that his sister was unlawfully killed but did say failings of BUPA staff had contributed to her death.
Mr Bloom, a car dealer from Chigwell, Essex, has vowed to fight on, even after the unprecedented third inquest.
"It used to be about Carmel," he told the JC. "But after the second inquest it became about the public interest.
"This verdict falls far short of what it should. Carmel was let down, she was seriously let down by her carers and the system has let down the family."
He now plans to refer the case to the Crown Prosecution Service (CPS), as he claims that evidence from expert medical witnesses was withheld. In addition, he hopes to pressure the GMC into reopening the case against the doctors involved.
The first inquest in 2003 found Ms Bloom died of natural causes but that verdict was quashed by the High Court in December 2004. A year later the second inquest said lack of post-operative care at the BUPA hospital, now run by Spire, contributed to her death. That finding, deemed inadequate by the Bloom family, was also quashed.
The new inquest was ordered in 2014, at the request of her family who said fresh evidence had come to light, and after the family commissioned an independent report from Professor Charles Weissman, of the Hadassah medical school in Jerusalem.
Giving her verdict, Ms Monaghan said: "Carmel Bloom's death was contributed to by the absence of regular monitoring."
She said Dr Hines's recommendation that Ms Bloom's deteriorating vital signs should be recorded every half hour was not followed by staff.
"Staff did not call Dr Hines until 2.55am, said the coroner. He arrived 20 minutes later, then himself delayed calling Dr Timmis until 4.29am. By this time Ms Bloom was suffering from pulmonary oedema.
Dr Timmis did not intubate, ventilate or monitor any of Ms Bloom's vital signs during transfer, said Ms Monaghan.
Speaking after the inquest, Mr Bloom said: "We now have the urologist being culpable, the anaesthetist and the BUPA nursing staff being culpable, so it is one step further than before.
"If she had been ventilated, if she had been intubated she would have lived."
Mr Bloom, who represented the family himself in court, described the latest inquest as a "stitch up.
"It was farcical and a very glaring whitewash."
He described the "unrelenting mental and physical pressure" he and his family have been under since 2002, blaming a system that is "utterly corrupt".
"I'm just Bernie Bloom. I'm just a person in a system. This country is shameful," he said, adding that he and his wife plan to emigrate once the matter is completely settled.
"If I hadn't have done what I did in 2002 it would all have been swept under the carpet and nobody would have remembered Carmel Bloom - now no one will forget her."
Mr Bloom called for an investigation into the case and also criticised the GMC. "It is supposed to be there to protect the public from rogue doctors but all they do is protect rogue doctors from the public."
Bupa offered condolences but said, as it no longer owns the hospital, it could not comment further.
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