After getting it in the neck for the last few days from stupid people can I point the following out
Inquests do not establish if anyone was at fault or to blame for deaths - instead, they try to find out (and record) who the deceased was, how, when and where the deceased came by his or her death and the particulars needed for registration of the death.
Matters of blame or fault can only be pursued in separate civil or criminal proceedings.
The coroner may report the facts to an appropriate authority which may have power to prevent similar fatalities in future, but he or she cannot make recommendations or compel the authority to do anything.
