Senior Coroner Archibald Warner has defended his decision to hold just four inquests into sudden deaths in the last six years, insisting that no more were necessary.

And he told The Royal Gazette he had received no complaints from families about the lack of inquests since he took on the role in 2001.

“I don’t know of any cases where someone requests an inquest and it’s been refused,” he said. “If there is one, let me know, please.

“I am confident that I exercise my discretion judicially in each and every decision I make concerning whether or not an inquest should be held.”

This newspaper has recently reported how the Senior Coroner rarely holds inquests, apart from in the four situations when he is required to do so by law: when someone dies in police custody, in prison, in a senior training school or in a mental hospital.

That means there has not been a single inquest into the 70 road fatalities since 2008 or into many other unnatural deaths, including drownings, fires, suicides, workplace accidents and drug overdoses.

Mr Warner, who is also the Senior Magistrate, said the Coroner’s Act 1938 gave him the power to hold inquests in such cases, but he rarely found it necessary to do so.

“We have never done a whole lot of coroner’s matters, inquests, in Bermuda,” he said. “I am not declining to do them in any specific case. I neglect to do them if on the facts presented to me they don’t merit [it].”

He added: “The vast majority of unnatural deaths in Bermuda are road traffic accidents and, generally, the police investigation is of such a high quality and the reports are so thorough that it is clear what caused the accident, what caused the death.”

He pointed to a recent report from the Department of Health, which found that alcohol played a major role in Bermuda’s road traffic fatalities, with eight of the road deaths in 2010 and four in 2012 involving alcohol.

Mr Warner said: “If someone gets on a cycle on some drinking establishment in Front Street and come[s] up East Broadway speeding, impaired, under the influence, and misjudged the turn down by the end and hit a wall, and there is someone driving in the right-hand lane who witnessed it, or even if there is not a witness, why should there be an inquest into it?

“[It was a] simple, straightforward accident. The investigation shows exactly what happened.

“If it is clear how the accident happened and there is no question of who is to blame for the death — in other words, there is no question of a third party or another party being involved or even if there is another party involved but the investigation clearly indicates what happened — then why should an inquest be held?”

The Senior Coroner’s stance differs from comments made by Commissioner of Police Michael DeSilva in 2011, who said key lessons could be learned from holding public inquests.

Mr Warner said he didn’t think holding inquests into road fatalities would improve road safety, highlight the Island’s drink-driving problem or deter people from driving under the influence.

“I don’t think there is need for an inquest for them to know, for the public to know, that people are dying on the roads because of drunk driving,” he said. “It necessarily follows that if you drink and drive, there is a chance you are going to kill yourself.

“Don’t blame the Coroner for that. Yes, there is a problem with drunk driving in Bermuda. People have got to stop. I believe that there is a well-known public campaign about the dangers of drinking and driving and the results of drinking and driving, as seen in the accidents.

“Just because there is a toxicology report that indicate[s] that you are over the limit, does not, in itself, merit the holding of an inquest.”

He said neither the Coroner nor the police were obliged to publicise the cause of every sudden death, adding: “Why should the public be necessarily told?”

He added: “I cannot think of any reason why we would want to suppress information about sudden deaths.”

The Senior Coroner said he would make the police report on any unnatural death available to “all the parties” but agreed that didn’t make it a public document.

It is within the Coroner’s powers to make recommendations after a sudden death where, for example, an accident was caused by a dangerous stretch of road.

But Mr Warner insisted not one of the 70 road deaths since 2008 had warranted such a course of action.

“None of them have thrown up a set of situations that would merit me making such recommendations. I review each and every case on its merits, individually, and there is a full report from the police.”

Mr Warner said if relatives who had lost loved ones requested an inquest, he would consider holding one.

He said his decision would be based on various factors. “There are a number of matters you have got to take into consideration: cost, these days; court time; all these matters. Of course, the overriding interest is fairness.”

He said cost wasn’t the number one reason but was a factor. “Cost and time associated. But that alone, by itself, would not be reason not to hold an inquest in the appropriate case.

“As you know, we are chock-a-block in these courts with regards to not only work but slots, in the Magistrates’?Court. And that is not to say that we should treat our duties with regards to Coroner’s matters lightly, but it’s a question of balance.”

He pointed out that Bermuda does not have a dedicated coroner’s court, nor an independent investigatory arm, and could struggle to hold more inquests if the public demanded it.

He said the fact no one had complained to him about the lack of inquests in his 12 years in the post suggested “maybe then I’m right, in exercising my discretion in that way”.

Apart from the Norman Palmer inquest, the other three inquests held in recent years were into the deaths of Mid-Atlantic Wellness Institute patient Shandal Richardson and Westgate prisoners Lorenzo Robinson and Keno Outerbridge.

Mr Warner has recently ordered inquests which have yet to take place into a drug overdose death, a suspected suicide and the death at King Edward VII Memorial Hospital of bar owner Hubert Brown (see separate story).