I mean often I was doing the cases pro bono because there was no legal aid for these cases, so there was a team of us who were doing this work pro bono. And INQUEST was then able to report and get journalists interested in reporting these cases, so instead of just being some small item on the back page of a local newspaper, they were being reported in The Guardian, in The Independent, sometimes on the BBC.
So I remember the Philip Knight case in particular. He was a 15-year-old boy who was remanded into Swansea Prison, an adult prison, and killed himself, hung himself, I think, on the day that he was remanded into custody. And it got a huge amount of publicity nationally as a sort of scandal of neglect of a young person. And so that was, in a sense that was the plus side of it is that INQUEST was able to get publicity, as an organisation it was able to support families and then get publicity, which in turn created a momentum in the public sphere to change practices within prisons.
Now, but my experience was that the learning process was extremely slow and you did, after years after these cases began to be reported, you know, the same thing would be happening time and time again. But, so there was that aspect to it in terms of what you were, what was being revealed about how these mistakes, these errors, this incompetence was taking place. Then in terms of the law, on the back of the publicity and the knowledge of what was going on, there was a litigation strategy to enable juries, coroners’ juries, to return verdicts which enabled the jury to set out what they found. The so-called lack of care narrative verdict. And that, it seems like a sort of obvious thing now, but at the time the law was very strict – I’m talking about in the eighties and early nineties – the law was very strict that the coroners’ rules made clear that a jury was not allowed to express a view about civil or criminal liability in giving a verdict.
And so after a long process of an inquest it was revealed horrendous incompetence directly relevant to how someone had died, in the end the jury was just left with, well, was it suicide, was it an open verdict, usually those were the only two options. And then the lack of care verdict was given some power and strength by the case law changing in the High Court and the Court of Appeal to enable juries to deliver what became known as narrative verdicts. And that was very important, because juries were finally able to set out what they thought about, in answer to the question how did someone come by their death, they were able to give a meaningful answer to that question, which could then be the basis for the coroner to write to the Home Office or the police or whoever it was to identify what the failings were in the hope that lessons would be learned and practices would change.
