25

The relatives of those who died when the Marchioness went down had doggedly been pursuing their case all these years. Now they won a victory. When their attempts to persuade the coroner to reopen an inquest had got nowhere, they had turned to the Court of Appeal, which agreed that, by refusing them an inquest, the coroner was ‘in real danger’ of showing unfair, though unconscious, bias. As a result, an inquest was finally held by another coroner. Six years after the disaster, in 1995, the inquest jury agreed nine to one that the victims were ‘unlawfully killed’.

There was no one to prosecute now, since two attempted prosecutions of the Bowbelle’s master had failed, but the verdict fuelled the relatives’ belief that there should be a public inquiry. An action group continued to push for one. Their efforts were resisted by the authorities because there had been a complete overhaul of river safety as a result of the accident and it was argued that there would be nothing now to be gained by a public inquiry. The action group did not agree. Although it must have taken a great personal toll on them to continue their fight, the relatives insisted there was more to learn from their suffering and that a public inquiry was the best forum.

No one ever forgot the missing hands of the victims, and I was still held responsible for this. So, while I agreed with the reason the relatives wanted an inquiry, I dreaded it. Because the whole subject, including those hands, would surface yet again.

Pressure from the ground up on intransigent authorities was also evident in other important cases at that time. The investigations into the deaths of Joy Gardner and Stephen Lawrence, two years on, just seemed to be fizzling out. Except that there were many people who were not going to let that happen. First relatives, then whole communities, set out to mobilize public opinion by showing that, in the case of Stephen Lawrence, racism in the Metropolitan Police was hindering the investigation. In the case of Joy Gardner, they had to show that someone other than a court had decided to exonerate the officers involved.

At first, not much changed in the Lawrence investigation. However, to the astonishment of the Met, who insisted their staff had only been doing their job, prosecutors now charged three officers with the manslaughter of Joy Gardner.

At that trial, the QC gave me a cross-examination I shall never forget. Someone had leaked a copy of an early draft of my report on the case, and he pointed out that in my final draft there were over seventy changes. He dragged me through them, one by one, asking me to justify every word change, deleted comma or additional semi-colon. I felt my minor revisions (for instance, changing probably to possibly, or quickly to rapidly) made little difference to the overall case, but it was useless to say that in each draft I was refining and clarifying. The QC’s clear implication was that I worked closely with the police and had been leaned on to make them appear less culpable for Gardner’s death.

Our exchanges went something like this (and I am writing from memory since no transcript seems to have survived):

QC: Let us look at here … why did you revise the word ‘severe’ to ‘moderate’, Dr Shepherd? For that was certainly a dramatic revision.

ME: It seemed on reflection a more appropriate description.

QC: But why was it more appropriate?

ME: Well, I considered all the facts again very carefully and revised my opinion.

QC: Are you sure that revision wasn’t based on the receipt of further information?

ME: It was based entirely on my analysis of the case.

QC: But why would you make so extreme a change if you had no new information?

ME: I felt it was more correct.

QC: So … are you saying you … changed your mind?

ME: Indeed, I changed my mind.

QC: You simply changed your mind! Changed it on a, on a, on a mere whim?

I can see why he was suspicious. Of course, I regularly worked with police officers and it might have seemed a fair assumption that I was trying to please them. In fact, no one had leaned on me. Nor do I try to please. Yes, it might have felt awkward working with the Met if I had been instrumental in convicting three of its officers, that is the sort of dilemma I had always known a forensic pathologist must face occasionally. I had hoped that I would respond bravely to pressure and treat truth as my greatest ally.

Scandalously to many, all three officers were acquitted.

Personally, although I could not condone their actions, it was clear to me that the officers were, themselves, victims in a way: victims of an entirely flawed system. They had not been trained or informed how to restrain safely, they had not been warned about the possibly dangerous effects of their actions. They did not know the rights or wrongs of Joy Gardner’s deportation. It was their duty physically to carry out the orders of bureaucrats who made their decisions on behalf of the British people. They thought that by restraining Joy Gardner they were simply doing the unpleasant job they were paid for. The fact that they did it so badly, I felt, reflected on their employer’s bad practice.

Joy Gardner’s sad death was a catalyst for change. For me it was the last straw. I knew now what I had to do. I became an active and enthusiastic part of, indeed sometimes the instigator of, bodies set up not just to review restraint procedures but to train properly anyone whose job requires them to restrain: principally police, prison and immigration officers.

It is impossible to know what will later be the significance, if anything, of one’s own life: I’d like to think that in my case it will be my contribution to this change. It has largely been a question of making a nuisance of myself, running training courses, organizing conferences, writing reports, sitting on committees but, most of all, education.

Detractors of the police may be surprised that I found most officers extremely keen to learn correct and humane restraint: they, more than anyone, were aware of the deficiencies in their practice. They, more than anyone, knew that it wasn’t just the families and friends of the victims who suffered, it was also officers’ lives and careers which could be completely changed by the events of a few minutes. However, it was many years before every single organization which can lawfully restrain, from the Border Agency to the Youth Justice Board, finally endorsed the set of principles for safer restraint that we succeeded in introducing to Metropolitan Police training after the Joy Gardner case.

I became a member of the Independent Advisory Panel to the Ministerial Board on Deaths in Custody. It is jointly sponsored by the Departments of Health and Justice, as well as the Home Office. Sounds bogged down in bureaucracy? It isn’t. That’s just how much elbow power we needed to ensure the set of guidelines I wrote would be approved and adhered to.

The guidelines recognize that restraint can have a significant psychological effect on everyone involved, including those who witness it. They set out the principle that restraint should be used only when it is necessary, justifiable and proportionate to the perceived threat. And they acknowledge the possibility that poorly applied restraint can lead to death. So only approved techniques should be used, and only by trained, authorized staff.

Once an incident is underway, management is essential. I like to think that the guidelines here were influenced by my flying experience. Where there are two pilots in a plane, only one is in full control and, when control is passed from one to another, both pilots must verbally acknowledge this.

PILOT 1: I have control.

PILOT 2: You have control.

This routine brings clarity in a crisis. So I had the idea of transferring aviation practice to the crisis which is a restraint situation. In this crisis, the person who is responsible for the detainee’s head, neck and breathing is the person in control. It doesn’t matter if it’s the lowest-ranking officer present, that person must take control by saying, ‘I now have control of this incident.’ The others must acknowledge with, ‘You now have control of this incident.’ Crucially, control gives the authority to order an immediate release and be obeyed.

There is more detail of course, involving medical monitoring, filming, records and debriefing. But the overall aim was to turn the rugby scrum of forcible detention into something used only when necessary, and in a well-managed and safe way. The result, I believe, has been a dramatic reduction in the number of restraint deaths by the authorities. In fact, it is now much more dangerous to be arrested by a fellow citizen or shop or nightclub security staff.

After the acquittal of the officers in the Joy Gardner case, there were calls for a public inquiry. Which were resolutely resisted. As for the Stephen Lawrence case, it was clear the police investigating knew some names and had suspicions. However, no prosecution followed and so Stephen’s parents and friends began a heroic and dignified struggle for justice. They pressed ahead with their own civil prosecution of three of the five alleged killers.

I was called as a witness at this trial. Michael Mansfield QC was acting for the family in the unaccustomed position of private prosecutor. But it was all to no avail. The world watched as the proceedings collapsed almost before they started for lack of evidence considered admissible by the judge. Worse, the double jeopardy law at that time meant that the three who were tried could never again be tried for the same crime and it seemed that all possibility of justice was lost for the Lawrence family.

However, they did not accept this. They now demanded an inquest. It seemed public opinion was fully behind them. Many had been shocked by the acquittal of the officers involved in the Joy Gardner case. Now people were beginning to believe that the investigation into Stephen’s case was hampered by the same sort of racism that had led to his death, and even a public inquiry – established only at the behest of a government minister and something considerably larger in scale and much more legally powerful than a coroner’s inquest – began to look like a real possibility.

The Lawrence family’s patience and persistence finally did lead to an inquest. The five suspects were ordered to appear. They did so, but refused, as was their legal right at an inquest, to answer any questions. The coroner, who is not legally allowed to actually name murderers, was helpless in the face of their rude silence. However, the jury found a way around that and cleverly concluded, in February 1997, that Stephen Lawrence had been ‘unlawfully killed in a completely unprovoked racist attack by five white youths’. They might as well have said ‘… by the five white youths sitting over there’. And the Daily Mail more or less did so, publishing pictures of the five, naming them, and inviting them to sue if the Mail was wrong.

Public scorn at the failure to apprehend Stephen’s attackers reached such a pitch that at last it really began to seem that demands for a public inquiry into the Met’s investigative failures would be met. I was personally delighted by this strong move for change which was now forcing a rethink in official and police culture. It had not escaped my notice that so many of the deaths in custody or under restraint I had been dealing with were the deaths of black people, and, put simply, the potentially increased vulnerability of some individuals through sickle-cell trait certainly did not explain this disparity. I could see change was necessary, but I could not imagine how change might come about. It never occurred to me when I examined the body of Stephen Lawrence that precisely those knife wounds would, over the next twenty years, be the precipitating factor in that change.