Coroner: You’ll remember Prof Shaw was then taken to what you may think is close to the heart of the issue, these three elements, could she say on balance of probability whether her recommendations had been followed the outcomes might have been different.

Coroner: You’ll remember Prof Shaw was then taken to what you may think is close to the heart of the issue, these three elements, could she say on balance of probability whether her recommendations had been followed the outcomes might have been different.