POSITION PAPER

14 November 2000

1. Introduction

   1. The Marchioness Disaster of 1989 was an example of how things can go wrong. The emergency notification sent the River Police in the wrong direction and the rescue operations proved to be inadequate and too late for 51 people. From the identification of bodies through Coroner proceedings and insurance settlement, there was confusion, lack of openness and honesty, and an inordinate amount of time for completion of each step. It has taken 11½ years to have an open inquiry into the Disaster. Disasters become public deaths. The process in itself has added additional trauma and stress that prolongs long term grieving and adjustment for both the Families and the Survivors.

   2. It begs the question of whether the "open public court" of the Coroner System, for any form of sudden death especially in regards to disasters, is viable in this age of specialist organisations. Such organisations can independently meet the needs of recovery and identification of bodies, post-mortem examinations as necessary and otherwise meet the government requirements and still provide a caring, private, and humane service to the Bereaved Families. The ultimate test of any organisation is its ability to meet the needs of the society, which it purports to serve.

   3. There have been improvements over the past few years. Although not a statutory requirement and left to each Force/County to implement, they do represent an increase in awareness of needed change on the part of officials in the public and private sectors. The establishment of Disaster Management Training Courses and trained Police Family Liaison Officers is a case in point. While still few in number these units provide an informational and support link between the police and public. Thorough training of personnel in these units is a recognised necessity. Strong emphasis is placed of sensitivity training in relating to victims and their families. Organisations, such as Disaster Action and Victims’ Voice, are among the many organisations getting attention placed on the rights of victims and victimisation caused by thoughtless acts or an uncaring system. MAG strongly supports all such efforts and hopes that this trend will become ever more evident in its spread throughout the UK.

   4. There are many geographical and political units within the UK. Undue financial burden can be placed on the local ratepayers of the jurisdiction in which a disaster occurs. The organisation of emergency services varies greatly in number and scope. Much time was wasted in the Marchioness Disaster with various services debating who was responsible for what. There needs to be centralised schemes covering the whole of the UK providing expertise and resources to meet disaster needs wherever they occur.

   5. This paper addresses the affects on the emotional and physical health of Families and Survivors that resulted from their involvement with the Marchioness Disaster. There is no intent to ignore the many that also experienced severe health problems, breakdown in personal and family relationships and financial ruin, but the consideration of these tragic circumstances is left for another time.

   6. Recommendations:

      1. Recommendations are made for changes that can minimise the adverse affects produced by the disaster management process itself.

      2. Responsibility for implementation of recommendations must be clearly established along with an expected completion date and a schedule for reporting progress towards completion and honest accurate information at every stage.

2. The Survivors

   1. Survivors related that they experienced much confusion while they were in the water and in a number of cases, almost run down by rescue craft.

   2. For many, there was no one to meet them when they reached shore, no central collection point or clear direction as to what they should do or what would happen next.

   3. Recommendations:

      1. Besides better safety practices and the availability of floatation gear on the boats and onshore, there needs to be a co-ordinated approach to the rescue process and to the treatment and processing of survivors.

      2. For those not going to Hospital, there needs to be an assessment of functionality and ability to care for themselves before being released. A 24-hour medical observation period would be desirable.

      3. Statements should not be taken without considering the physical and emotional state of the survivor.

      4. Survivors should not be used to notify families of dead or missing loved ones (as occurred in the Marchioness Disaster).

      5. Full and honest accurate information should be given at all stages.

3. The Bereaved Families

   1. There was no sense that there was an orderly progression of events after the Disaster with no voluntary information provided to the Families. Everything somehow was dependent on the dictates of the "system." The atmosphere was one of containment and control. Information was on a need to know basis. The authority was in the "know" and the Families and Survivors were left with the "need."

   2. Notification of Families was inconsistent and in many cases done in an unprofessional manner often by telephone and not in person by untrained officers. Key family members were not notified. Two examples: 1) parents of a married child were not informed, and 2) divorced parents, only one was informed. These lapses in notification caused much distress to these parties.

   3. There was a general lack of information about the status of recovery of bodies.

   4. When bodies were recovered, families were not notified until, in some cases, days afterwards. Most families were prevented from making a personal identification of the body of their loved one often given the reason that the body was unrecognisable from being in the water so long (a fact that was untrue). Denial of right to view was then and is contravening to existing law.

   5. Post-mortems and special examination/toxicology tests were performed without the required notification. This contravened existing Coroner Laws in conjunction with the 1961 Human Tissue Law.

   6. Bodies were released to local undertakers with instructions prohibiting their viewing and in some cases the bodies were missing hands.

   7. Families received no information or counselling regarding their "rights" under the law.

   8. There is no legal aid that Families can turn to for assistance in supporting the costs of legal representation at an inquest.

   9. The majority of TV and print media were very intrusive, lacking in consideration for people’s feelings adding another burden to those already experiencing extreme stress.

   10. Recommendations:

       1. There should be a thorough review by an independent body of the Coroner System to see if it is viable in this age of specialist organisations in dealing with any form of sudden death and especially when it comes to disasters. The emphasis should shift in "ownership" of the body from the Coroner or the State to the Family with due respect given to religious and social beliefs as well as the "rights and wishes" of the dead and those of the Family.

       2. At the present time Coroners are appointed. They should be trained in performing the duties of a coroner and be required to pass a qualifying examination. They should have a Contract of Employment with provision for complaint and dismissal procedures. There is no continuity or consistency in the present Coroner System. There needs to be uniformity throughout England, Wales and Northern Ireland. Accountability needs to be given to the ratepayers supporting the system.

       3. A systematic approach to notification should be established and followed.

          1. Information about the Family should be gathered at the same time the information form for the deceased is being completed. This information should include the Family member/structure, religion, family doctor, medication, and other special needs. This information can help in determining how contact with the Family might best be done and needs for future assistance.

          2. Trained Police Family Liaison Officers should actually do the notification and be alert to the special needs of the person or family that may be revealed during the initial contact. Notifying the family doctor of the Bereaved/Survivor of the situation (with their consent) would be desirable, as there may be long-term implications and or insurance claims/court proceedings. Local service organisations should be alerted to insure backup support should the need arise.

          3. The assigned Police Family Liaison Officer should remain the primary contact throughout the disaster activities and should give complete and accurate information about the disaster and ongoing activities.

       4. A communications centre should be established to provide Families with accurate, up-to-date information. The establishment of 24-hour disaster "hotlines" manned with good listeners is actively supported.

       5. Provision must be made for Families and Survivors to remain near the central command area if they so desire and if their home is too distant to make it a reasonable commute. Food, restroom, medical facilities and a quiet place to wait should be provided and located convenient to information sources but shielded from media intrusion.

       6. Written information in large print for the Bereaved/Survivors to review in their own time should be provided. This should include honest accurate information covering their rights under law and give a clear statement of the procedures to be undertaken.

       7. Changes in Legal Aid and other regulations are needed to provide practical financial assistance covering necessities (e.g., travel, accommodations, etc.), and for legal representation that may be required at different stages of the disaster.

4. Legal Processes

   1. A formal inquiry of the Marchioness Disaster was delayed for 11½ years unduly lengthening the period of stress for the Families and Survivors.

   2. The Crown Prosecution Service (CPS) functions within its own sphere of activity without consideration or respect for the "rights" of victims or their families.

   3. Court proceedings blocked completion of the Inquest in 1990 and further investigation or inquiry into the Disaster because of subjudicy prohibition of any "public" discussion of the case.

   4. Recommendations:

      1. There needs to be a requirement that every disaster must be followed by a Public Inquiry exempt from any Ministries or perceived interested parties. Consideration should be given to whether the Police should have sole responsibility for the investigation. Resources should be made available to provide specialist support that is not in their remit. The Public Inquiry should:

         1. be conducted immediately following the disaster;

         2. have full judicial powers and authority of law;

         3. not permit immunity from prosecution; and

         4. Allow no other legal matters concerning the disaster until the conclusion of the inquiry.

      2. Require the CPS to provide consideration and representation to victims and their families at least to the level that the law provides for defendants.

5. Insurance Settlements

   1. The processing of insurance claims associated with a disaster is arbitrary, capricious and inherently unfair.

   2. The settlement process can be drawn out for years since there is no incentive to keep it short. Fees are usually based on time involvement.

      1. Fees not explicitly covered by insurance can significantly reduce the amount of the settlement that a claimant receives.

   3. A psychological assessments required as part of the claims process that get placed in medical records can have an adverse affect on future insurance applications of a claimant.

   4. Recommendations:

      1. No final settlements of insurance claims should be permitted until the conclusion of the inquiry.

      2. Establish an independent board with no financial interest in the insurance settlement to administer the insurance settlement scheme.

      3. Establish a payment structure to be applied to all claimants of a given disaster.

      4. Prohibit any requirements for claimants to undergo any procedure that in itself can have an adverse affect on future insurance coverage.

      5. Establish a time limit for insurance settlement. Completion within 18 months following the conclusion of the inquiry should be required.

6. SUMMARY

   1. Disasters happen and people are involved. It is not the point of this paper to address their prevention but to address factors that can reduce the trauma inflicted on those people involved in it. The consideration of life should always be placed ahead of property concerns.

   2. Besides the victims, all those involved with a disaster are affected to some degree by physical and emotional stress (i.e., emergency services, etc.). The physical trauma can be seen to heal but the affects of the emotional trauma remain for the lifetime of the person and often are not obvious outwardly. The affects do show up, however, in the ability of the person to maintain personal, family or community relationships. Suicides, divorces, health problems, and financial ruin are often experienced by those directly involved and those who may be several steps removed from it. These collateral affects are rarely acknowledged.

   3. The "three Cs" of Communication, Co-ordination, and Caring must become the mantra of any disaster management scheme along with honest accurate information. Bereaved Families and Survivors must be included in all aspects of the disaster and their needs must be given the highest priority. With attention given to these aspects, Disaster Management can become much more effective and humane than is currently the case.

7. An inscription in the Jefferson Memorial, Washington DC

"I am not an advocate for frequent changes in laws and constitutions, but laws and institutions must go hand in hand with progress of the human mind. As that becomes more developed, more enlightened as new discoveries are made, new truths discovered and manners and opinions change, with the change of circumstances, institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which fitted him when a boy as civilized society to remain ever under the regimen of their barbarous ancestors."

Thomas Jefferson