Page 109 - When Things Go Wrong

bereaved people and survivors at the centre of proceedings; with some notable
exceptions, the reality falls far short of that aspiration.

7.4. Meaningful participation depends first and foremost upon an understanding of
the process, which in turn depends upon proper communication as to what it is
for, what is involved, what is to happen and when. People thrown into the
system need to know from the outset what part they can play, whether they can
be represented, and if so whether their representative will be able to ask
questions, and whether they will be able to see any documentary material. The
importance of effective communication cannot be overstated.

7.5. However, implementing proper communication is only part of the solution.
The Working Party recognises that institutional defensiveness of State and
corporate bodies in inquests and inquiries, so graphically described in
Patronising Disposition, can only serve to undermine public confidence and to
prolong hearings with the likelihood of a consequential increase in costs borne
by public funds. We consider that the proper observance of a statutory duty of
candour would be likely in many cases to shorten proceedings, and contribute
to the cultural change necessary to prevent inquisitorial proceedings being
treated as adversarial.

7.6. We recognise that a number of our recommendations, such as the
establishment of an Independent Advisory Board to the Central Inquiries Unit,
a coroner services inspectorate, and a National Oversight Mechanism for
monitoring the implementation of recommendations, will have cost
implications. But it is our considered view that our recommendations, if
implemented and when viewed as a coherent set of proposals, could in the
long-term lead to significant savings to the public purse by the reduction of
delay, duplication and future recurrence.

7.7. Inevitably, there were further issues raised during the course of our work that
that fell beyond the scope of our recommendations. The Attorney General’s
fiat; the role of the media and of insurers; public interest immunity;
undertakings; deaths arising from movement of people through migration; 306

306 On this issue, see the work of the Last Rights Project coordinated by the charity Methoria.
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