No one is to blame for the mix-up of two car crash victims which resulted in the wrong body being buried, a senior judge has found.
Mr Justice Weir, a High Court judge and presiding judge for the coroner's service, carried out a review of events following the deaths of Danica O'Rourke and Anita Swift from Co Fermanagh last summer.
They were among four young people who died instantly when the car in which they were travelling hit a tree along the Newtownbutler to Lisnaskea road early on July 2nd last.
Danica was wrongly identified as Anita and was buried by the Swift family on July 4th. However, an examination of dental records showed that the family had buried the wrong body.
Danica's body was exhumed and reburied on July 7th after a second funeral for Anita was conducted privately.
The judge's 30-page review of the mix-up was written after speaking to those most closely involved in the case.
It details the events from shortly after the crash until realisation that a mis-identification had occurred.
"The initial error made in the most difficult of circumstances at this dreadful scene was then adopted and acted upon in good faith by others."
Mr Justice Weir has established a "core group," to be led by the coroner involved, along with others from the PSNI and the department of health. This group will complete a best-practice guide for coroners, which will include specific procedures for dealing with the identification of deceased persons.
Mr Justice Weir will oversee this work.
In particular he has asked the group to consider that, where in the same incident there is more than one casualty, whether killed or injured, of the same sex and within a similar age bracket and where positive identification of everyone in that category has not been conclusively accomplished, no body from within it should be released for burial until everyone in that category has been positively identified.
In a statement issued through their solicitor, the O'Rourke family thanked Mr Justice Weir for the sensitive approach he had taken in his review.