The unanswered questions about how 50 young people could drown in the middle of a river in Britain's capital city were behind the determination of their families and friends to bring about the lengthy inquest which finished yesterday.
But as well as seeking answers to those concerns there was the need for a kind of collective therapy. Margaret Lockwood-Croft, who lost her 26-year-old son Shaun in the disaster described the inquest as a "lanced boil".
Although the Marchioness disaster claimed more lives than the disasters at Kings Cross, Clapham or the M1 aircrash, the circumstances had not been fully examined, leaving relatives with a deep sense of frustration that has taken more than five years to resolve. Yesterday many families will have felt a strong sense of relief that some matters had finally been laid to rest.
At the beginning of the case, Dr John Burton, who has conducted other high-profile inquests, including those of the boxer Bradley Stone and the MP Stephen Milligan, seemed determined to give the families the opportunity to speak freely about the children they had lost and what they felt should be changed.
Eileen Dallaglio, who lost her 19-year-old daughter Francesca, a graduate of Elmhurst Ballet School, spoke for nearly an hour without interruption. It seemed as if the inquest was becoming a form of "group therapy" for those involved to come to terms with the grief and injustice they felt.
Others felt, though, that the inquests revealed that coroners had too much power in the way inquiries are conducted.
The second inquest was only needed because the coroner in the first, which was adjourned because of the prosecution of the Bowbelle's captain, refused to reopen the inquiry after the court case.
Joshua Rozenberg's book, The Search for Justice, describes the coronial system as "an autocratic procedure that would have been abolished long ago if it had survived any where else in the legal system".
During an inquest, the coroner alone decides which witnesses can be called. And the coroner alone addresses the jury on the facts of the case.
Louise Christian, solicitor for the families and a founding member of Inquest, which campaigns for reform of coroners' courts, said: "It gives him a great deal of control - it is his interpretation of the facts without challenge. I think it's wrong that there are proceedings in which the coroner has quite so much power," she said.
"There has been far too much comment about what was going on which if it was a criminal trial [the coroner] would have been stopped." Dr Burton had described witnesses' evidence as "becoming totally unreal".
Perhaps the greatest difficulty in this inquest came over Rule 22 - whereby the coroner is obliged to warn witnesses they do not have to answer incriminating questions. Confusion over what happened on the night of 20 August was exacerbated because of the absence of full evidence from the two men in the best position to know.
The skipper of the Marchioness, Stephen Faldo, died in the disaster and the skipper of the Bowbelle, Douglas Henderson, exercised his right under Rule 22 not to answer any incriminating question.
Mr Rozenberg called for the proposals of the Broderick report of 1971 to be implemented - that all coroners should be legally qualified and appointed by the Lord Chancellor. Most importantly, he wanted ministers to set up a new system of public inquiries into sudden deaths with the power to conduct investigations, apportion blame and award compensation.
Since 1977 a coroner has not been able to commit someone for trial on the evidence given. Neither can the verdict impute blame nor contradict previous legal proceedings.
Michael Burgess, secretary of the Coroners' Society, said this was the strength of the system: "Coroners can explain to the jury the different interests people have, but there are no pre-set ideas and the court is seeking to do something different to other courts. It's striving for the truth."Reuse content