For the couple, it was more than a matter of principle: it was their tribute to Krystal, the fulfilment of a pledge to ensure that no one else would have to suffer the grief and heartbreak that they had, when the means of preventing it were so plain.
Death and bereavement are part of life, of course, and it is futile to hope that we can ever make living risk-free. But to say that is a far cry from shrugging and turning away when expert opinion is pointing to a way of avoiding preventable death and injury.
In contrast to the medical-examiner model that is familiar to viewers of American crime dramas, coroners here are drawn from the ranks of the legal fraternity and judiciary. It is not their job to be experts in themselves, but rather to sift all the expert evidence they can call on - medical, legal and technical - to investigate the causes of deaths.
In addition, the Coroners Act specifically requires them "to make ... recommendations or comments that ... may, if drawn to public attention, reduce the chances of the occurrence of other deaths in circumstances similar to those in which the death occurred".
A more digestible version of the same idea is found on the Coronial Services website: "Sometimes the coroner's findings will show that something needs to be done to prevent deaths occurring in similar circumstances. The coroner can draw attention to this by making public his findings and may write to someone in authority about the issue, for example the council or a government department."
All this sounds great. But as our stories over the past few weeks have revealed, coroners' recommendations are too often being ignored - either wilfully or carelessly. In at least a dozen cases over the past five years, recommendations have not been acted on: in six cases, incredibly, the recommendations were lost; in five, they were disregarded; and another four were deemed too expensive to implement. In far too many others, authorities have not explained what, if anything, they have done to fix the problems.
It is time that this official indifference, laxness or bungling came to an end. There can be no point in having a coronial system if its recommendations are not vigorously followed up. When judges pass sentences, they are enforced; Corrections don't put them in the bottom drawer, lose them or wait for more funding.
A coroner is also a judicial officer and, if his recommendations do not have the force of law, they are not made idly. The Justice Department must set up a monitoring system that follows up on coroners' recommendations to make sure they are implemented, and investigate the ones that are not. It need not be an expensive and cumbersome piece of bureaucratic machinery. But it would serve to make sure that people like Krystal Bennett did not die in vain.
