Page 8 - When Things Go Wrong

EXECUTIVE SUMMARY

When a catastrophic event or systemic failure results in death or injury, the justice
system must provide a framework to understand what happened and to prevent
recurrence.

This Working Party of JUSTICE was established in recognition that the legal
processes designed to fulfil these aims are too often beset with delay and duplication,
with insufficient concern for the needs of those affected by disasters. Instead of
finding answers through the legal process, bereaved people and survivors are often
left feeling confused, betrayed and re-traumatised. The lack of formal implementation
and oversight following the end of an inquest or inquiry makes the likelihood of
future prevention limited.

Having sat for a year, this report records the 54 recommendations of the Working
Party, which seek to ensure that the justice system’s response when things go wrong
is consistent, open, timely, coherent and readily understandable:

The framework for reform
Inconsistency is a problem for both inquests and inquiries. In the coronial jurisdiction,
local authority control with little centralisation means that standards and practices
can vary greatly. Meanwhile, the decision to establish a public inquiry is a political
one and, at the outset, important practical decisions are made without drawing upon
best practice from those with previous experience. The result is a lack of transparency
and an unnecessary waste of time and resources. In order to increase coherence, we
propose new State and independent bodies to provide oversight and facilitate
information-sharing.

Duplication of process can cause anguish, delay and expense. We propose a full-time
Chief Coroner role to provide greater oversight and a special procedure inquest for
investigating mass fatalities as well as single deaths linked by systemic failure, able

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