Mr. Roger Murray:

First, with regard to recommendations, the model is there from the jurisdiction in England and Wales. In 2013, it introduced a new set of coroners rules that made it mandatory for a coroner, if information became available to that coroner during the course of an inquest, to come back with what is called a prevention of future death report. Let us take the example of an accident on a railway where there is a lacuna relating to safety equipment, for example, a guard rail. I came across a situation recently where the windows on some trains can still be lower down, and in that particular inquest the coroner made a recommendation to the authority in charge of the train that it must fix or remedy this problem. The way it works is very interesting. The coroner identifies the lacuna and the person who has the responsibility or the ability to fix it. Crucially, the coroner does not tell the person how the coroner thinks the person should fix it. The onus is on the person to whom the coroner is writing to come back within eight weeks with details of how the person proposes to fix it. A report must not only go to the individual coroner but also go to the chief coroner. Those prevention of future death reports are mandatory if a coroner identifies it in the context of an inquest.

At present, recommendations are returned by inquests and juries throughout this country that have moral authority and that certainly have saved lives, in my opinion and in my experience, but the difficulty, as has been identified by this committee, is there is no follow-up and there is no penalty if somebody does not respond to them. There is no legal imperative or obligation on them to do that. We add our voices to those calling for the recommendations to be put on a statutory footing. The model is there - the prevention of future deaths reports in the UK. Perhaps Ms O'Mahony has some thoughts on that.