"For example: the coroner was initially undecided about whether a jury should be present at the final hearing. Though an independent report found that Connor's death was preventable and Slade House was subsequently shut down after failing an inspection, Sara says that at the pre-inquest review the Trust's lawyers still argued that Connor died of natural causes and that he had not actually been detained in the unit, so a jury would be unnecessary. "
"The first argument – that a death by drowning was not unnatural – was immediately dismissed by the coroner. But the second was less clear cut. "The argument about whether or not Connor had been detained was relentless," says Sara. "It probably took our barrister about 20 minutes of careful arguing, holding up case law and all the rest of it, for the coroner to eventually accept that he was. And we would never have been able to do it on our own." A jury inquest was granted. "
"For Mr Dias, this kind of legal wrangling is to be expected at a state death inquest. He says that families initially come to him relieved that their relative's death will finally be investigated. "I have to advise them, time and again, you must understand that this will be terribly, terribly difficult," he says. "Because when something like that happens, rather than throwing open its doors to expose systemic wrongdoing and individual and collective failures, the state closes the doors and you have to bash them open."