Lawyer Elizabeth Christopher?s point was well taken in yesterday?s when she questioned what purpose inquests now serve if Coroners are unable or unwilling to find fault or hold anyone accountable.

The question raises a number of worthy legal issues which have to be considered seriously. But in some cases, legal principles seem to be at odds with common sense. The bottom line is that the current system of inquests fails to satisfy anyone.

Inquests can be held into any violent, unnatural or sudden death. They can also be held for any death which occurs when a death takes place in some form of custody.

Under current British law, inquests determine who the deceased was, how, when and where the person died, and the particulars to be registered.

Until recently, the Bermuda courts system allowed coroners? juries to name a person?s killer as a result of an inquest and this could be used as the basis for an indictment in the Supreme Court.

And Coroners also used the power of their post to identify negligence or to criticise safety equipment, dangerous roads and the like. For an example, if a person was killed in a road crash because the helmet they were wearing was sub-standard or because the accident occurred on a dangerous corner, the Coroner could raise these problems. While the finding had no force in law, it would be a foolish Government (or business) that ignored such a finding.

Nonetheless, an inquest is not and never has been a trial. There is no accused person, and witnesses, while entitled to legal representation, do not have the same rights of cross-examination and so forth that a defendant would have.

On that basis, it is dangerous for a Coroner to make accusations after what is only a partial inquiry.

But common sense dictates that in situations where a faulty piece of equipment, inadequate safety measures or a negligent person or institution contributed in some way to a person?s death, then the Coroner should have the right to say so, if only to warn others and to prevent repeat occurrences.

It is worth remembering that in the UK, inquests were either never held or failed to properly identify the causes of death of elderly persons under the care of Dr. Harold Shipman. Finally, it was revealed that he had murdered 215 of his patients, the bulk of them women.

Now the UK has undertaken a massive review of its system of Coroners and inquests.

Home Office junior minister Paul Goggins said last year when the Government tabled a position paper on the subject that: ?Most deaths do not require detailed scrutiny or judicial investigation but we must ensure that families can find out how their relatives died and that avoidable deaths are prevented.

?The proposals outlined today will introduce a new system that will combine an independent check on all deaths and a professional oversight of death patterns, with, for the majority of cases, the minimum of bureaucracy.?

That?s a reasonable starting point for a review of the Island?s system. One of the key findings in the UK paper is for the establishment of full-time medical examiners. Bermuda has had a patchy approach to pathology in the past, especially with regard to suspicious deaths. The appointment of a full-time medical examiner or forensic pathologist in Bermuda would be a good first step.