One by one, the solicitors arrived at the coroner's court. They looked confident and prepared. They clearly knew their way around the court. Four different organisations were represented at the inquest, including the local mental health service. That meant four different solicitors.
The bereaved mother, Kim, and her family sat side by side in the public waiting room. They remained silent, watching everyone who arrived. They huddled together on the bench, as if protecting each other.
This was an initial hearing to decide what needed to be covered at the full inquest. Immediately the coroner informed the parties that she was considering designating this an 'article two' inquest. I wondered if the family knew what this meant. They had no solicitor to guide them.
An article two inquest happens when a state organisation such as the NHS or the police may have failed to protect the life of a person. Families who have concerns about the care their loved one received prior to their death often appreciate the fact that this type of inquest allows a broader, more in-depth investigation. The four solicitors argued that this should not be an article two inquest. The family didn't make any submissions. The coroner agreed with the solicitors' view.
Afterwards Kim told me that she felt "completely out of her depth". How daunting it must have been, without legal knowledge and up against four experienced solicitors. Unrepresented families sometimes describe feeling that this is a "David and Goliath" situation.
Kim's son had ended his life a few months ago. She felt very strongly that he had been let down by the organisations responsible for his care and wanted the inquest to uncover this. The wider remit of an article two inquest would have been helpful in this respect. And importantly, families can get legal aid for a solicitor at this type of inquest - something which isn't available for most inquests. The family needed a solicitor to argue the case for article two at that pre-inquest hearing. They were so disadvantaged.
Kim told me she felt defeated. She felt her son would be simply a statistic.
Generally families represent themselves in a legal procedure which forces them to re-live the most painful aspects of their loved one's death. It cannot be right that we expect bereaved families to do this.
I run a Suicide Crisis Centre. Our work involves supporting people who are at risk of suicide. However, we have now decided to start providing support to families at inquests as well, because of the emotional impact of the process, and because they are usually unrepresented.
We witness the huge courage of families as they seek to find out the truth about the death of their loved ones. Last week a young woman, Jess, asked to make a statement in the coroner's court after the full inquest had finished. Her father had taken his own life, but the coroner could not conclude that it was suicide because it must be proved "beyond reasonable doubt" that it was intentional. Jess walked to the witness box. In an act of remarkable bravery, she challenged the coroner's verdict (now known as the conclusion). She said that her father had expressed suicidal intent and she had warned a number of organisations that he was at risk. This had not come out during the inquest, because Jess had not given evidence.
I think the manner of her father's death was such that she expected that the conclusion of the coroner was going to be suicide, and so she didn't ask to give evidence. Many people don't realise the "high bar" required for a suicide conclusion. It must be proved beyond reasonable doubt - it is not enough that the "balance of probabilities" indicates suicide. If bereaved families had immediate access to legal advice, they could be advised about this.
Jess simply wanted the truth to come out. And she had spent months preparing her younger siblings for a suicide conclusion, explaining to them that there should be no stigma to it.
We were relieved to find out recently about the excellent organisation Inquest, which can give advice and help to people facing an article two inquest. We now put families in touch with them. When it's not an article two hearing, we can still sometimes get legal advice from other sources which we pass on to the families.
Recently an inquest was adjourned so that the coroner could consider calling additional witnesses, including a patient on the psychiatric ward where the young woman in question had ended her life. The solicitor for the mental health trust argued that the patient's evidence shouldn't be included as they felt "her mental capacity was in question" at the time of the young woman's death. The family didn't challenge this.
I decided to make some enquiries. Initially I went to the advising psychiatrists within our charity and then, as the issues became more complex, I emailed a specialist lawyer in London. I simply did a google search and found one of the most experienced lawyers in the country. To my surprise, he replied almost immediately, giving me all the information I needed to show that the evidence of a sectioned psychiatric patient should be considered just as potentially credible as any other witness statement. I was able to send this to the coroner's court.
It's wonderful that dedicated lawyers are willing to help in this way. But we need to make it possible for families who have been bereaved by suicide to have access to legal advice from an early stage. And should we really expect them to represent themselves in court, in such a harrowing and emotionally distressing situation?
For information about the Suicide Crisis Centre: http://www.suicidecrisis.co.uk
Suicide Crisis on Facebook: http://www.facebook.com/SuicideCrisisCentre
INQUEST : http://www.inquest.org.uk