More just as a point of information about the Coroner System:
I came across a letter to the editor from a paper in Australia (through a Google search and “feed”) that mentions an important point about the Coroner’s system: “The focus of a coroner’s inquest is to establish a cause of death, not whether anyone was at fault.”
As the author of the letter states: “This prohibition can seem strange to people unfamiliar with the coroner’s role.” Indeed, this does cause some confusion for jurors and, at times, the friends and family of decedents. Particularly in certain cases everyone wants to assign blame, somebody must be responsible. But blame/fault-finding is specifically precluded from the proceedings. It is the job of the police and the legal system (criminal and civil) to assign blame/responsibility.
The Coroner and the inquest decide the cause and the manner (natural, suicide, homicide, accident, undetermined) of the death. Findings from the Coroner’s Office investigation and inquest may be turned over to the “authorities”, but they may not be admissible in court.
Liability is the purview of the other branches of Justice, as it should be.