The Royal Gazette’s report last week on the lack of inquests held into unexpected and unusual deaths begs a literally existential question: how many lives might have been saved if more inquests had been held in the past 20 years?

The answer to that will never be known, but it is a legitimate question to ask, given that the island has held only four inquests in the past decade, during which time there were 981 sudden deaths.

Inquests do not just determine the cause of death and provide closure — although those are important in and of themselves — but they can prevent further deaths by showing that a life-saving medicine could have been used in one instance, or a traffic-calming measure could have been placed in a frequent crash spot in another.

Some of these things happen now, but they are inconsistent and often kept secret. The impact of a coroner making a public statement with regard to a clear risk, and recommending that it be changed, can have an immediate impact on public awareness and can spur authorities to action.

The Gazetteexclusive, written by Sam Strangeways, highlighted a number of instances of this, including the death of the newspaper’s former reporter, Chris Spencer.

In that case, his mother, Lynn Spencer, publicly campaigned for an inquest and got one. While his inquest concluded that his death could not have been avoided in the immediate circumstances, it led to the requirement that a potentially life-saving drug, Narcan, had to be carried on ambulances for treatment of victims of heroin overdoses.

Ms Spencer said: “The benefit that the inquest had was that the ambulances now carry Narcan. That’s huge.”

More broadly, the inquest also laid bare an addiction problem that is rarely discussed in Bermuda. Someone somewhere may have read the report of the inquest and decided to get help for themselves or a loved one. That could and probably did save lives.

Other inquests held over the past ten years — into road deaths, drownings, health problems and other causes — could have had a similar impact.

But they haven’t, because some 18 years ago the courts decided that inquests were too much trouble.

According to present and past court officials, they used up too many already stretched resources, required too much already limited preparation time, may have seemed invasive in a small community and may have interrupted or diverted attention from other pressing cases — cases where those involved were still alive.

All of those reasons carry some validity. Inquests do take time and resources. The courts are clearly overstretched. In some instances, inquests bring more pain than they do closure or they invade the privacy of people who are still mourning.

But that does not mean that virtually no inquests should be held. Bermuda has the dubious distinction of not holding an inquest into the death of a man who received the wrong blood transfusion, even after a Supreme Court judge ordered that it should take place.

It may be that before the law was changed in 1999, and before senior magistrate Archibald Warner decided in 2007 to drastically curtail the number of inquests being held, that more inquests were being held than was necessary.

It is also true that court administrators must balance the need to hold inquests against the other duties of the court to hear criminal and civil cases.

And there will be instances where a public hearing into a death is indeed too invasive and painful for families and friends, without necessarily serving a greater public need.

But there must be a better position than what Bermuda has at present, where to all intents and purposes, no inquests are held — and even when they are, they are often years late.

Some judges and magistrates agree on this.

Juan Wolffe, then the senior magistrate, said of Mr Spencer’s inquest: “I think it’s an inquest that needed to be heard.

“It’s never going to give complete closure, but hopefully it answers some questions, and hopefully by having an inquest we can learn more about how to deal with those who fall prey to drug use.”

Ruling on Hubert Brown’s inquest into a fatal blood transfusion, former puisne judge Stephen Hellman said of inquests generally: “It has long been recognised that there is a public interest in the coroner holding an inquest where there is reasonable cause to suspect that a person has died a violent or unnatural death or a death of which the cause is unknown.

“These are matters which are rightly of concern to the community, and an inquest gives them the opportunity to understand what has happened and why.”

The problem lies in the 1999 amendments to the Coroners Act, which gave coroners wide discretion not to hold inquests, a power that appears to be a blanket ban. Only deaths in prison and industrial accidents receive a mandatory inquest — and even these often take years.

No discretionary inquests are held unless there is rare and heavy public pressure.

The law needs to be changed to force the coroner — usually the senior magistrate — to show cause why an inquest should not be held, rather than the existing situation where no reason need be given.

Families should have greater rights and an easier means to seek an inquest. Getting closure may not be sufficient reason on its own, so a family should also have to demonstrate a clear public interest.

And in incidents where privacy is warranted, the coroner should have the discretion to close the hearing, but should be required to explain why — based on clear criteria.

In some instances, public and private bodies do draw conclusions from tragedies and change practices to prevent them happening again. But this is a scattershot and secretive approach when consistency and transparency are needed by the families and the public in general.

Bermuda deserves better than to be the island of no inquests, where sudden deaths are rarely explained and lessons are infrequently learnt. The Coroners Act needs to be amended, while the sitting coroner needs to change an approach that was surely not intended when the Act was amended 26 years ago.

It is literally a matter of life and death.