Mr. Roger Murray:

The Deputy has hit the nail on the head. I would refer to the prevention of future death guidelines in the UK from the chief coroner in England and Wales. He said the prevention of future death reports are vitally important if society is to learn from deaths. He also said coroners have a statutory duty rather than simply a power, where appropriate, to report about deaths with a view to preventing future fatalities. He further said a bereaved family will be able to say a person's death was tragic and terrible but at least it is less likely to happen to somebody else. He said prevention of future death reports, PFDs, as they are called, are not intended as a punishment; they are done for the benefit of the public. The guidance goes on to state in regard to PFDs that they should not be unduly general in their content, that sweeping generalisations should be avoided and that they should be clear, brief, focused, meaningful and, wherever possible, designed to have practical effect. The model is there with respect to what prevention of future death reports should look like. They save lives. I know that because I have seen carefully crafted recommendations. I would echo what Professor Cusack said. I would commend juries on their ability, after hearing days of evidence, to distil it down into four or five net points. In large measure, the recommendations are practically capable of being put into effect. Deputy Costello is correct in pointing out that currently there is no follow-up in regard to it. There is nobody saying the coroner in County Clare made this recommendation a month ago and, therefore, it is redundant for you to say it. I think if there was that level of scrutiny, more lives would be saved.