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Dr Freddy Patel's report on Daniel Abrey suggested he may have examined the body of a man almost a foot shorter
The pathologist who concluded that Ian Tomlinson had died of a heart attack at the G20 demonstration is suspected, in another case, of doing an autopsy on the wrong body.
Dr Freddy Patel's report into the death of Daniel Abrey, a 22-year-old civil servant, indicated that he had examined the body of a man almost a foot shorter and without the same identifying features.
The mix-up was never resolved, prompting a coroner at Abrey's inquest to say: "We know the right person died, we know the right person was buried, but there is a missing step."
The coroner was forced to record an open verdict, leaving Abrey's devastated family with many questions about what they say was his unexplained death in a north London bedsit in September 2005.
His mother, Hilary Abrey, 59, is one of a number of families with concerns about Patel's postmortems who have told the Guardian that they have lodged complaints with the General Medical Council in recent months.
He was later contradicted by three forensic pathologists, all of whom examined Tomlinson's body and said that the cause of death was internal bleeding in the abdomen. They were backed by a number of medical experts who gave evidence at the inquest.
During the inquest, it also emerged that Patel altered his notes to identify marks on Tomlinson's body and changed the description of fluid found in his abdomen a year after conducting the examination on 3 April 2009.
Details of his errors in the Abrey case are likely to intensify demands for Patel to be struck off.
He is no longer registered on the Home Office list of forensic pathologists, and has been suspended twice in the last seven months by the GMC, after being found guilty of conducting botched postmortems and falsifying his CV.
Hilary Abrey, who considered exhuming her son's body when she read that Patel had recorded that her 6ft 1in son was 5ft 4in, still receives counselling for the trauma of not knowing whether her son's body was examined.
Although the postmortem report should have noted identifying features, it contained no reference to her son's lip piercing.
"I want to know how Daniel died – what happened?" Hilary Abrey said at her home in Waltham Abbey, Essex. "Did he die quickly? Did he die slowly? Was he in pain? I'm going to go to my grave without knowing any of that."
Her son's inquest in St Pancras, north London was temporarily suspended in December 2006 when the confusion arose. Patel told the court: "It didn't strike me at the time that the body was 6ft 1in. I think at the time the technician measured without taking into account rigor mortis."
However, Patel conducted the postmortem four days after the death – rigor mortis, when it occurs, usually dissipates within three days.
The coroner, Andrew Walker, told Hilary Abrey: "I'm as maddened as you are by the measurements that don't make sense, by the statements that don't tally."
The coroner said he could not rely on Patel's conclusion that Abrey, who worked at the Inland Revenue, died of a pulmonary oedema. "Unless we start knowing that Dr Patel carried out a postmortem on Daniel Abrey, we can't continue."
Reconvening the hearing weeks later, Walker said the cause of death was uncertain.
Patel said in a statement that he had not been notified of any complaint from Hilary Abrey, adding: "As I am expecting to attend a review hearing by a GMC fitness to practise panel in the summer, it would be inappropriate for me to comment on any matters before that hearing takes place."
However, Patel addressed the issue in correspondence with Hilary Abrey in the months after her son's death. In a letter to her, he maintained that the fault was with his assistant technician.
Hilary Abrey replied that the pathologist should take responsibility, adding: "I will never know how my son died. How will I ever know? There is no going back and checking who you actually examined."
In his reply, Patel gave no guarantee over his examination, saying only it was "unlikely" that the autopsy was on the wrong body. He added: "I am very sorry that you have judged me unfairly."