Coroner: You should also know, I referred to it when I summed things up to you, that I have a duty if issue were raised during evidence heard that action needs to be taken that action needs to be taken to prevent deaths in the future about how the person came by their death.

Coroner: You should also know, I referred to it when I summed things up to you, that I have a duty if issue were raised during evidence heard that action needs to be taken that action needs to be taken to prevent deaths in the future about how the person came by their death.