Reports & recommendations

The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the loss of life and the injuries suffered by those who survived.

Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the Merchant Shipping (Formal Investigations) Rules 1985, as amended.

I recommend that in the future both the Department and the MAIB take steps to ensure that dealings between them are limited to those matters which necessarily arise in connection with the performance by the MAIB of its proper investigatory functions, including of course reporting to the Secretary of State.

In these circumstances I recommend that clear guidelines be laid down setting out precisely the role of the MAIB on the one hand and the role of the Department on the other. Such guidelines should be published so that the public may know the demarcation line between the Department and the MAIB and have confidence in the MAIB in the future.

Further, I would also recommend that strong advice be given, both in the manual and in any training course which officers are required to undergo, that requests for the removal of body parts only be made after consideration on a case by case basis, taking into account all other available means of identification.

If, contrary to my recommendation, the appropriate Secretary of State orders a public inquiry into any of these matters, I recommend that he consider whether there might be a case for including it, not with an FI, but with an inquiry such as the Alder Hey Hospital Inquiry.

In any event, I recommend that post mortem procedures be kept under review. Those procedures include the removal of body parts generally, the recording of any decisions to remove body parts and the reasons for such decisions, issues of consent with regard to removal of body parts and permission to attend a post mortem and also issues regarding permission to view the deceased at various stages.

The Secretary of State should exercise his power under section 268 of the Merchant Shipping Act 1995 to cause a formal investigation to be held into the collision between the MARCHIONESS and the BOWBELLE, the loss of the MARCHIONESS, the loss of life and the injuries suffered by those who survived.

Although I take the view that the remit of a formal investigation would include the search and rescue operation, I recommend that the Secretary of State give an express direction to that effect in accordance with regulation 4(1) of the Merchant Shipping (Formal Investigations) Rules 1985, as amended.

I would also reiterate the recommendations which the inquest jury, although not strictly empowered to do so, made in a letter delivered to Dr Burton with their verdict on 7thApril 1995: 1. Families of victims must always be informed of their rights to attend or elect medical representatives to attend post mortems. With appropriate counselling, they should be offered the opportunity to view their relative’s body. The issue of visual identification must, however, be treated with caution. 2. Removal of hands for the identification of bodies should be done only when all other methods have been exhausted (especially the matching of dental records) and not as a matter of expediency. In such circumstances, mortuary technicians and pathologists must remember that a procedure which may seem standard to them, is likely to be deeply distressing and offensive to relatives. 3. We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.