Anyone questioning why it matters so much that a Fatal Accident Inquiry (FAI) take place promptly after a death need only read the judgment of Sheriff Linda Ruxton at the end of the FAI into the tragic death 10 years ago of teenager Kathryn Beattie.
Kathryn died aged 13 in 2004 from a fatal brain haemorrhage caused by undiagnosed leukaemia. The sheriff ruled that there had been confusion at the Victoria Infirmary in Glasgow when she was admitted but nothing could have been done to save Kathryn's life once bleeding had begun in her brain.
She was highly critical, however, of the massive delay in holding the FAI. All aspects of the inquiry are adversely affected by such a delay, she noted; it is intolerable for the deceased person's family and unacceptable for the medical professionals involved in the case.
Memories fade, she continued. Where there is serious public concern that lessons ought to be learned from the incident, there is a risk to public safety if relevant issues go unresolved.
Huge delays, moreover, can impair the quality of the evidence. It is not only that accurate recollection becomes more difficult, but "the passage of time allows genuine memory to become corrupted and there is the risk that it becomes affected by external influence".
Where there are such long delays, she added, medical records take on a central importance, but in Kathryn's case, those records were incomplete, in come cases inaccurate and some notes went missing. All in all, the case for holding FAIs promptly is unanswerable.
Some efforts have been made to address delays. The Crown Office notes that it has set up a specialist unit to improve matters and procurators-fiscal make extra efforts to ensure FAIs reach court quickly once a decision has been made to hold one.
But it is not enough. The Crown Office in this particular case has made the point that there was a delay of three years in the circumstances of Kathryn's death being brought to the procurator-fiscal's attention, but the sheriff makes clear that, nevertheless, there was an unacceptable delay in bringing the matter to court.
The idea of setting up three specialist FAI centres around Scotland to handle the cases, thus saving them from competing for time in the courts system, has been mooted and that could help, but more decisive action is needed.
For instance, at present, FAIs are postponed until after any criminal case associated with them has concluded. It has been suggested that, like English coroners courts, FAIs could run in parallel with criminal proceedings, provided they focused on matters not related to the criminal case. Unfortunately, the Scottish Government at present has no plans to take forward such a reform.
Deaths in tragic circumstances, where there is a suspicion they might have been avoided, cause untold distress. It is the responsibility of ministers and the Crown Office to find innovative ways to bring these terrible delays to an end.