Public opinion and in particular the media attention in response to the findings of Coroner JP Ryan in respect of the accidental death of Iraena Asher are misguided. It is the role of the Coroner to ascertain the cause of death and any contributing factors to prevent future deaths in similar circumstances and to make recommendations where deemed necessary.
This process is inquisitorial and is not about apportioning fault or blame. The 'unpopular' finding relates to the Coroner's determination that notifying emergency services may have prevented Iraena's death and this finding was directed at the couple who assisted Iraena in her distressed and vulnerable state. The finding is not suggesting that the couple were required to do more than the good deeds that they did in fact do on that night, it is simply suggesting that there is a chance that if emergency services were involved the Iraena's death may have been prevented. The point Coroner Ryan was making was for the benefit of the public, that if they find themselves in a similar situation then the best action to take is to notify emergency services rather than taking it upon yourself to provide care and assistance alone.
Another point raised is that the Coroner ought to have given notice to the couple advising of the findings he intended to make public before actually making them publicly available. The Coroner is required to act in compliance with Coroners Act 2006 and as such it is at his discretion whether or not the findings will be made publicly available. Additionally, it is unlikely that Coroner Ryan intended for his findings to bring about the controversy that has transpired nor would he have come to his conclusions with the intention of causing any distress to the couple that he in fact commended for their actions in caring for Iraena on the night of her disappearance.
The last point I will address is the suggestion made by the media that the Coroner made these findings based on two days of hearing evidence. This is misleading. The investigation starts from the moment the death or in this case the report of the missing person is notified to the Coroner. Prior to the inquest, the Coroner undertakes a full and thorough assessment of the evidence and information provided by the various agencies, family members, friends and so on. The Coroner will then make requests for further information and will look to experts and anyone other person that the Coroner thinks may be able to assist in the inquiry. Coroner's do not turn up cold to inquests. The finding that Iraena's death was likely an accidental drowning is not just some assumption the Coroner plucked out of the air. It will be a rationally based conclusion in consideration of all the evidence he had available to him including the two days of evidence heard in the Coroners Court.