Inspectors say it still needs to improve how it investigates patient deaths - but is getting better.
Southampton Man Unlawfully Killed In Afghanistan Attack
A coroner has ruled a Labour MEP candidate from Southampton, who died from gunshot wounds to the head and chest following a suicide bomb attack in Afghanistan, was unlawfully killed.
Dhamender Singh Phangurha, known as Del Singh, died in the attack on a restaurant in the capital, Kabul, on 17 January which killed 21 people including senior UN officials, Afghan dignitaries and restaurant staff.
The inquest in Winchester, was told that the Taverna Du Liban restaurant was frequently used by foreigners as it was considered a safe and secure place.
But the explosion created by the suicide bomber killed the security guards at the entrance and breached the steel door, allowing two terrorists carrying AK47 rifles to enter the premises and shoot indiscriminately at staff and customers, the inquest heard.
Central Hampshire Coroner Grahame Short was told that Mr Singh, 39, from Southampton, was an international development specialist who had extensive experience managing EU and UN projects in post-conflict countries including Afghanistan and Sierra Leone.
At the time of his death, he was working as an international aid adviser for Tour Afghanistan, a subsidiary of Adam Smith International, ensuring that aid coming into the country was going to the right places, the inquest heard.
Mr Singh and his friend, Gnanathuria Nagarajh, a Malaysian national who also worked for ASI, were killed by insurgents at about 7.20pm on January 17 as they dined at the restaurant.
Simon Chase, a former British soldier from Limavady, Co Londonderry, was also killed.
A statement from Richard Ironside, a manager with Tour Afghanistan, said Mr Singh and his team would always report their movements from Victor 8, the guesthouse where they were living, to the operations room.
He said the Taverna Du Liban was deemed a safe place because it had a steel reinforced entry gate, security guards, people entering would be searched and there were also alternative exit points.
Shortly after the men arrived at 6.52pm, Mr Ironside heard a loud explosion, the inquest heard.
He said: ``A call then came in from Del.
``He was saying 'I am at the restaurant, I am at the restaurant. I can hear firing in the background'.''
Mr Ironside said he could hear rounds being shot and then the phone went dead, the hearing was told.
He tried calling Mr Singh back but only discovered he was dead and had been taken to Camp Phoenix several hours later, the inquest heard.
A post-mortem examination carried out by forensic pathologist Dr Debbie Cook and forensic firearms expert Khaldoun Kabbani showed that Mr Singh had suffered four gunshot wounds - two to the head and two to the chest - which would have killed him immediately.
Dr Cook said there was no indication that he had been injured by the bomb blast outside the restaurant, the inquest heard.
Acting Detective Inspector Matthew Potts, from Thames Valley Police's South East Counter Terrorism Unit, said it was still not clear exactly what had happened but that the bomb outside had allowed the two gunmen to breach security and gain access to the restaurant and the people inside.
He said: ``It does look like it was more of an indiscriminate attack on the occupants.
``Some staff and diners managed to escape out of the restaurant through the kitchen.
``Local police have not been able to establish who was responsible for this attack.''
He told the coroner that investigations were continuing in Afghanistan but it was believed the attack was carried out by terrorists, although the motivation was unknown.
Dishi Kaur, Mr Singh's younger sister, broke down as she told the coroner she still found her brother's death hard to talk about but said Mr Singh was ``a really great man''.
Recording his verdict, Mr Short said: ``When deaths happen abroad I have limited powers to investigate.
``However, based on the evidence that I do have, I think Del was killed at random and deliberately by terrorists.''
He went on: ``I suspect they were trying to disrupt the government and election that was then in progress.
``The insurgents themselves were killed but I believe their intention was to kill as many people in the restaurant as they could, themselves knowing that they would die.
``Del was trying to help the government and people of Afghanistan and it is clearly a great tragedy that he died in this way.''
Following his death, Mr Singh's partner, Komal Adris, 35, said he had advised Labour leader Ed Miliband on Israeli and Palestinian policy and travelled regularly to Afghanistan.
He had been a Labour candidate for this year's Euro elections and Mr Miliband paid tribute to him after the incident, saying: ``He dedicated his life to working with people across the world who needed his support.''
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