"Drawing these strands together, my conclusions were as follows. First, that the duty of the coroner was limited to a duty to investigate those matters which caused, or at least arguably appeared to him to have caused or contributed to, the death. Secondly, that the claimant was unable to show even an arguable case that any body was at the material time under a duty, statutory or otherwise, to establish a health-based place of safety at a time, and in a location, such that Miss Speck could have been taken to such a facility in June 2011. Thirdly, that the claimant was therefore unable to show even an arguable case that Miss Speck's death was caused or contributed to by a breach of such a duty. Fourthly, that the coroner was therefore correct to decline to investigate issues as to the non-availability of a health-based place of safety: to have done so would have been to investigate matters which fell outside his statutory duty under section 5 of the Coroners and Justice Act 2009. Lastly, that even if I had been persuaded that it was within the coroner's discretion to investigate such matters, I would have found there was no basis on which it could be said that his decision not to do so was a perverse or otherwise unlawful exercise of that discretion."