Ken,
While in no way referring to this specific case, my understanding is that UK coroners have the power to write a report to any party or organisation in the interest of preventing future deaths. In my very limited layman's experience, however, coroners are very reluctant to take this course of action unless there is no doubt that a death could and should have been prevented. In this case, I think that - in theory at least - there will be 11 inquests. (I imagine that would also apply in the US?)
JFZ90,
Assuming the coroner's remarks have not been misreported, I entirely agree with your sentiments in this case.