1989 to 1997 On the day following the collision
Paul Knapman, the
coroner for the
City of Westminster, opened and adjourned the
inquest into the deaths. In the days after the collision, bodies were still being found and recovered from the water. To help with the
identification process, Knapman opted to use several methods, including dental records, identification of personal items and clothing descriptions from descriptions provided by the families, and fingerprints. As part of their approach, Knapman decided that: With those bodies which were not recovered from the
Marchioness and which would be likely to surface only when putrification and bloating meant that they would float, the following would apply: During the
post-mortem examinations, 25 pairs of hands were removed; no written records were kept of the removal. No guidelines were issued over which hands should be removed and no individual was given responsibility for making the decision. The majority were identified through other means—visual identification of the face, or through identification of clothing or personal items, and only four of the victims were identified through their fingerprints. Families of the victims later complained that they were not told in a timely fashion that bodies had been recovered, that some were denied access to view the bodies of their relatives, and were not told of the processes that would be used—including that the hands would be removed. One family was shown the body of the wrong person, then given the right body, but without the hands; these were sent on later with apologies, and a request not to tell other parents about the need to remove them as this was a 'one-off' mistake. On 24 August
Marchioness was taken from her mooring near Southwark Bridge, and towed downstream to Greenwich, where she was broken up. The MAIB issued an interim report towards the end of August, with recommendations as to increasing safety on the Thames. These included a requirement that vessels over had to have a forward lookout in contact with the bridge by radio, and tighter controls on the passage of vessels along the upper Thames. Their investigation continued with a reconstruction of the events on the night of 16–17 September;
Bowbelle took part, and a PLA launch was used as a stand-in for
Marchioness. This was later criticised by Brian Toft, a disaster and risk-management expert commissioned by the Marchioness Action Group (MAG), as being unsatisfactory. Toft identified that there were several problems, including no second pleasure cruiser, no fare-paying passengers and no disco lights or music included in the re-enactment. In October 1989 the companies behind
Bowbelle and
Marchioness agreed to pay up to £6 million in compensation to the families of the victims, without either company admitting any liability for the crash. The sum offered was under a
calderbank condition that the offer stood to be withdrawn if a judge awarded a lower amount. A week later a report was compiled for
Allan Green, the
Director of Public Prosecutions (DPP), which recommended that criminal charges should not be brought against Henderson. That December, Knapman met the DPP to discuss the progress of the inquests. Green agreed that the first part of the inquest should go ahead—dealing with the causes of death—irrespective of the other investigations of the police and the possibility of later criminal charges. A second part of the inquest—establishing the responsibility of the crash and making safety recommendations—would be discussed at a later stage. When Knapman re-opened the inquest on 23 April 1990, he was critical of the DPP for taking eight months to decide on whether to bring criminal charges against anyone, which meant that a full inquest could not take place in case it prejudiced any future trial. The inquest was, in effect, a series of what the legal scholar Hazel Hartley calls "mini inquests", one each for each of the 51 bodies. On 26 April the DPP stepped in to stop the inquest, stating that charges would now be brought against Henderson. Because of his decision to stop the inquest, the information on how the collision occurred, who was to blame or what could be done to ensure it could not be repeated, was not considered. Henderson was charged under the
Merchant Shipping Act 1988 for failing to have an effective lookout on the vessel. The case against him opened on 4 April 1991 at the
Old Bailey and ran to 14 April. The jury
failed to reach a decision; the DPP decided that a retrial would be in the public interest. This took place between 17 and 31 July the same year; it again ended with a hung jury. At the end of July 1991 Ivor , the husband of one of the victims, began a private prosecution for
manslaughter against four directors of South Coast Shipping Company, the owners of
Bowbelle, and
corporate manslaughter against the South Coast Shipping Company. Two weeks later the Transport Secretary,
Malcolm Rifkind, took the decision to publish the MAIB Report, repeating that because an appropriate body had undertaken an investigation, there was no requirement to have a public inquiry. Families of the victims were angry with the move, pointing out that Rifkind had delayed publication of the report on the basis that publication could prejudice the case against Henderson, but that the publication could now jeopardise private prosecution. The DPP demanded that hand over the papers for the case, stating he would take it over, then drop it; refused to comply, stating that it was out of the remit of the DPP, and that it was for a magistrates' court to decide if the case was adequate. The DPP withdrew and allowed case to proceed. The case was dismissed after the magistrate stated that there was insufficient evidence. investigation. (Not to scale) The MAIB report considered that
Marchioness had altered her course to port, which put her in line with
Bowbelles path. The report concluded that: 18.3 ... no one in either vessel was aware of the other's presence until very shortly before the collision. No one on the bridge of BOWBELLE was aware of MARCHIONESS until the collision occurred. 18.4 The principal contributory factors were that: The families of the victims criticised the MAIB report. They pointed out that the investigation had not directly interviewed anyone on
Marchioness or
Bowbelle, but relied on the police interviews; they stated that there were errors in methodology, approach and fact within the report. Toft provided a critique of the MAIB's work and concluded that: The inconsistencies, contradictions, confusions, conjecture, erroneous conclusions, missing and inappropriate recommendations as well as epistemological, ontological and methodological problems, created by the then current maritime safety culture ... raises serious doubts as to the objectivity of the investigation, the validity of the findings, the judgement of the Department of Transport in holding an inquiry of this type, and as a result whether or not all the appropriate lessons were uncovered during the MAIB's inquiry into this tragedy. The report was handed to Rifkind, who again declined to open a public inquiry, but commissioned a private one—the Hayes Report, published in July 1992—that looked at health and safety on the Thames, rather than the sinking of
Marchioness. In 1992 the families of the victims became aware that the hands had been removed from many of the bodies. In March that year an account in
The Mail on Sunday, "Cover up!", was published; when Knapman met the two journalists to deny the accusation of a cover-up, he advised them not to base reports on what Margaret Lockwood-Croft, the mother of one of the victims, said: he described her as "unhinged". He also showed them photographs of the victims, without discussing the matter with the families. In July, Knapman informed the families that the inquests—suspended since April 1990 because of the case against Henderson—would not be recommenced. The families tried to apply for a
judicial review on the basis that "the use of the word 'unhinged' and reference to a number of 'mentally unwell' relatives betrayed an attitude of hostility, however unconscious, towards ... members of the Marchioness Action Group". Initially turned down by High Court, the
Court of Appeal then found in favour of the group to allow an appeal. In June 1994 Knapman and his assistant were stood down and replaced by another coroner, John Burton. He was initially dismissive of the concerns of the MAG, accused their solicitor of trying to mislead the Court of Appeal and indicated that he was inclined not to grant any further inquests. Burton was told that another judicial review would be applied for if he refused to hold the inquests, and he subsequently announced that they would go ahead. The resumed inquest took place in March and April 1995. When questioned about the MAIB report, Captain James de Coverley—one of the report's authors—withdrew the suggestion that
Marchioness had steered to port in the last moments before the crash, saying it had never been his intention that the text could be understood that way. In summing up, Burton instructed the coroner's jury that a verdict of
unlawful killing could not be applied to anyone who had already been cleared by a court. The jury retired for four hours and returned a verdict of unlawful killing. Burton asked them "Did you understand my Direction?", but the decision stood.
1997 to 2001 Following the
1997 election, which brought the
Labour Party to power, the MAG petitioned
John Prescott, the
Secretary of State for the Environment, Transport and the Regions and
Deputy Prime Minister, to open an inquest. In August 1999 he instructed
Lord Justice Clarke to undertake a non-statutory inquiry into safety on the Thames. Clarke reported in February 2000, concluding: I was asked to advise My answer to that question is yes. Prescott accepted the recommendation and the public inquest took place in October and November 2000, with Clarke chairing proceedings; the report was published in March 2001. Clarke concluded that "The basic cause of the collision is clear. It was poor lookout on both vessels. Neither vessel saw the other in time to take action to avoid the collision." The underlying causes on why neither vessel saw the other were that Henderson did not ensure a proper lookout on
Bowbelle; that Blayney the lookout was not equipped with suitable radio equipment to inform his captain; that Faldo had not set up a lookout system on
Marchioness, nor did he keep a lookout aft himself. Focusing on Henderson, Clarke wrote "We cannot stress too strongly how much we deprecate Captain Henderson's conduct in drinking so much alcohol before returning to his vessel as master"; Clarke added "but we do not think that it is shown on the balance of probabilities that Captain Henderson would have acted differently if he had not consumed the alcohol or had the amount of sleep which he had". The captain was also criticised for his actions after the collision, when he did not broadcast a
mayday call and did not deploy either the lifebuoys or life raft, in contravention of section 422 of the
Merchant Shipping Act 1894. Clarke also found that the owners and managers of the vessels held some blame. For
Bowbelle, the owners "must bear their share of responsibility for the collision for failing properly to instruct their masters and crews and for failing thereafter to monitor them"; the owners of
Marchioness gave no instructions about all-round lookouts; and failed to adequately instruct, supervise or monitor their boats' captains. Clarke also allotted blame to the Department of Transport, who, he said, were "well aware of the problems posed by the limited visibility from the steering positions on both types of vessel" yet failed to deal with the problem. The PLA also failed to act in this regard, and should have issued instructions for the placement of lookouts on such vessels. Clarke found that because no individual's actions could be ascertained as the single cause of the collision, a manslaughter charge would be bound to fail.
Compensation English law provides no compensation for fatal accidents, other than for funeral expenses, unless financial dependency at the time of death can be proved. In most cases, the families of the
Marchioness victims received little more than the cost of the funeral.
Louise Christian, the human rights solicitor who acted for the families of the victims, wrote that "When young unmarried people die in circumstances of gross negligence as here, death comes cheap and the boat owners and their insurance companies suffer little in the way of financial penalties". Civil claims for
compensation were brought on behalf of the victims' families; the amounts received ranged between £3,000 and £190,000. Eileen Dallaglio, the mother of Francesca Dallaglio, one of the victims, reported that she had been awarded £45,000. After the costs of having to go to the Court of Appeal to obtain damages, and the bills for the memorial and funeral service, she was left with £312.14. According to
Irwin Mitchell, the solicitors who represented the families, the amounts were "modest" because many of those killed were young, without dependants and had no established careers. Under the
Fatal Accidents Act 1976, damages were only paid to certain categories of people, and were based on the
economic loss to the victim. The saxophonist Josephine Wells, who had toured with
Tears for Fears and
the Communards, who was aboard the
Marchioness and had a cousin die in the disaster, subsequently suffered a nervous breakdown and was unable to work. She sued the owners of
Bowbelle and
Marchioness for loss of earnings and in 1997 she received £150,000 in damages. ==Aftermath==