bereaved

The Crown Office said it had undertaken "significant reforms" since Mr Marshall's case and that bereaved families "can expect investigations to be pursued with the vigour and expertise they deserve".

At the time the watchdog said it had taken the decision to reopen the investigation following representations by the bereaved families.

“Inadequate staffing at SSA directly harms the retirees, people with disabilities, and bereaved families the agency is responsible for serving,” Romig and O’Connor report.

Earlier, Sir Adrian Fulford, chairman of the inquiry, promised to do everything "humanly possible" to answer the questions of bereaved families and victims.

The verdicts were marked with singing outside the coroner's court, as bereaved families and survivors celebrated a hard-fought moment.