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When someone dies unexpectedly in this way, the state conducts an inquest to establish exactly what happened. Unlike court cases, inquests are supposed to be inquisitorial rather than adversarial: fact-finding exercises in which lessons are learned but no one is punished. So Sara was surprised to find out that Southern Health would be represented at Connor's inquest by an expert legal team paid out of government funds. If Sara wanted legal representation, she would almost certainly have to finance it herself."It's frankly scandalous," says Dexter Dias, a leading QC who has represented families at inquests for over 20 years. He recently acted for the family of Cherry Groce, the victim of an unprovoked police shooting which sparked the Brixton riots, after a petition signed by over 100,000 people succeeded in securing legal aid for her inquest. Dias says that inquests are consistently the most "forensically difficult" cases he comes up against as a lawyer – more so than murder or even terrorism trials: "The idea that untutored, bereaved families should either conduct the case themselves or pay out of their own pocket is a travesty."
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There are two main arguments used by policy-makers against reforming the UK's inquest system. The first is that inquests are informal affairs and coroners are capable of conducting thorough independent investigations regardless of who has legal representation. William Armstrong OBE, a former coroner of 18 years, disagrees. "Representation at inquests is profoundly, extremely useful and helpful," he says. "When I was a coroner it was always reassuring for me to know that a family was effectively represented by an advocate who could ask questions on their behalf, who understands what the Coroners Rules allow and don't allow, and ensures that the family's voice is heard."The second argument revolves around money. The Ministry of Justice is quick to argue that public funding for family legal representation is available in exceptional circumstances, and that automatic funding for everyone would be too expensive. But, Coles points out, exceptional funding is almost impossible to access—for a start, you have to provide detailed financial statements from even extended family members. "It's unbelievably intrusive," she says. "Many families retract the application because they just can't stand it." And as for the latter problem, the issue is not so much lack of universal funding for families as what Coles describes as the "inequality of arms" between them and the state. If the right of public bodies to legal representation at inquests were removed, the parties would at least be on an even footing, and the system would actually cost the taxpayer less.The wheels of justice may slowly be turning with regard to inquest funding for families. At a widely reported High Court judicial review hearing in March, Justice Green ruled that the current guidance on legal aid funding for families at inquests is misleading and unlawful. At this stage, though, it's unclear how much will change as a result—it all depends on policy decisions made in the coming months and years by the newly-elected Conservative government.For Connor's family, the verdict they achieved on Friday doesn't bring back their brother and son, but it does bring them one step closer towards achieving justice and improving the treatment of disabled people in the UK. "It has been a long and tortuous battle to get this far," they wrote in a statement last week. "Families should not have to fight for justice and accountability from the NHS."Follow Elaine Allaby on Twitter.Read: A Guide to Spice: The Drug That's Putting British Students in Hospital