Wiltshire apologised for the delay. She said there were ‘some’ resourcing challenges within the coronial area and the coronial service during the time of the investigation.

The JCIO said: ‘Ms Wiltshire also said that she adjourned the proceedings due to insufficient evidence. Whilst there had been subsequent difficulties in obtaining this information, Ms Wiltshire accepted that she had placed too much reliance on staff and could have been more proactive in reviewing the case to ensure that it proceeded.’