Individual at Manchester

Investigation into the circumstances
surrounding the death of a man
in September 2005 at HMP Manchester
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2006
This is the report of an investigation into the circumstances surrounding the death of a
man on 22 September 2005. He died, apparently by his own hand, in a cell in the
Healthcare Centre at HMP Manchester. He was 38 years of age.
The man was found at 9.50am, by a nurse on duty in the Healthcare Centre, suspended
by a bootlace attached to the window bars. The lace had been fashioned into a noose and
wrapped tightly around his neck.
A pathologist performed a post mortem examination on 27 September at a hospital in
Manchester. The cause of death was identified as: Asphyxia, Hanging. Toxicology was
also carried out. The toxicologists opinion was, drugs found within the man’s body were
consistent with therapeutic dosage and/or post mortem redistribution.
I offer my sincere condolences the man’s family and all those touched by his death.
The man had been in prison for just 15 days prior to his death, having been remanded in
custody on 7 September by Salford Magistrates’ Court when committed for trial at Crown
Court. He was to face charges of theft and causing a public nuisance. He had also
allegedly told a prisoner who worked in the Healthcare Centre, that he might face more
serious charges.
The man was subject to enhanced supervision at the prison as he was known to be at risk
of suicide and self harm, having told prison staff that he was thinking of taking his life. The
initial stringent conditions of the suicide watch were relaxed the day before he died.
During the last of several psychiatric consultations, the man had said that he was less
anxious than before, having received positive news about his case at a visit from his
solicitor that day. The psychiatrist, who had treated the man regularly, assessed that the
conditions could be relaxed but that he should stay on a special watch.
Staff and prisoners at Manchester share a feeling of loss and incomprehension that the
man, who to all outward purposes seemed to be in good spirits following news that the
charges he faced were less serious than he had at first thought, apparently took his own
life.
My investigators visited the man’s father at his home. The man’s father was close to his
son and, although they did not see much of each other, the volume and content of letters
his son wrote from prison show the love and respect he had for his father.
Two of my colleagues carried out this investigation on my behalf.
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North Manchester Primary Care Trust, carried out a comprehensive clinical review for
which I am most grateful
My thanks go also to the Governor and all staff at Manchester.
Every report on a death in custody makes very sad reading. This was a troubled man, but
it remains a puzzle why he apparently took his life when he did, and how he obtained the
means to do so. However, this is also a report that reflects very well upon both staff and
procedures at Manchester prison. There are times when even the best motivated staff
and the best designed systems cannot prevent a tragedy from occurring.
I make four recommendations and identify seven areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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Contents
Summary
Investigation methodology
HM Prison Manchester
Events leading up to the death
Events following the death
Clinical review
Conclusions
Recommendations
Good practice
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Summary
1. The man was born in Manchester and he had one brother. His parents had divorced.
The man’s mother died in August 2005. The charges for which the man was facing
trial came about as the result of her death, as amongst other things the man allegedly
continued to draw the benefits to which she had been entitled.
2. He enjoyed a normal childhood in the family home and on leaving school started work
as a painting and decorating apprentice. He became friendly with people older than
himself and he started to take drugs. His life style brought him into conflict with the
law, but this was his first time in prison.
3. When he arrived at Manchester, he said he was depressed and withdrawing from
heroin. He said also that he was ‘hearing voices’. He was located in an induction
wing and a suicide prevention and self-harm special care programme was put into
place. He said he had been taking unprescribed drugs. Commendably, on the day
that he arrived at Manchester, healthcare staff telephoned the Primary Care Trust
that had been responsible for his treatment. A member of the PCT gave immediate
information in respect of the man’s mental illness, and comprehensive documentation
arrived next day by fax. He also tested positive for a number of drugs. He was seen
by a member of Manchester In reach Mental Healthcare Team and commenced a
detoxification course.
4. On 9 September 2005, the man saw a psychiatrist who prescribed treatment. He
was not hallucinating at that stage. He remained on the induction wing and a further
appointment was made for 14 September. In the event, he was at court that day and
the psychiatrist saw him on 15 September. He decided to admit the man as an
inpatient in the Healthcare Centre. The suicide prevention management plan
continued.
5. The man appeared a bit more settled, but on 19 September he said he was feeling
suicidal. He saw the psychiatrist again that day and his medication was modified. It
was around that time, probably 20 September, that the man allegedly told a fellow
prisoner that he might be facing a murder charge.
6. A further psychiatric appointment was arranged for 21 September. When the man
went to his appointment he said he felt much better. He had seen his solicitor earlier
in the day and was relieved to find that the charges he faced were not nearly as
serious as he had first thought. A nurse who had seen him a day earlier in the
Healthcare Centre, was present at the consultation and she said it was like seeing a
different person. A weight seemed to have been lifted from him. As a result of the
consultation, the psychiatrist decided that while the self-harm supervision should
continue, its conditions could be relaxed somewhat. In essence, this meant that the
man was not subject to intensive scrutiny. The psychiatrist noted in the ACCT file
that he should remain in an anti-ligature cell within the Healthcare Centre. In fact, he
was not in an anti-ligature cell, although the psychiatrist clearly thought that he was.
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Although there are such cells, they were fully occupied at the time and the man
returned to his own cell which had previously been designated ‘anti-ligature’ but
which no longer met new specifications. It is possible that healthcare staff did not see
the entry in the file. If they did, they did not act on it as the man returned to his own
cell. The psychiatrist also made a note in the man’s main medical record to the effect
that he was much brighter and did not express suicidal thoughts. He wrote ‘Stop
intermittent watch’ but did not repeat the instruction he had made on the ACCT form
in respect of an anti-ligature cell.
7. The standard of this man’s medical care was very good. He saw the psychiatrist on
four occasions between 8 and 21 September. Records of those consultations are
comprehensive. It was apparent also during interview with my investigators that the
doctor had a clear understanding and cared deeply for his patient.
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Investigation methodology
8. My investigators opened the investigation with an initial visit to HMP Manchester on
27 September. They were briefed by the Governor and Safer Custody Manager.
They chaired a meeting and were briefed by staff who were involved with the man.
both during his short stay at Manchester and following his death. Police attended the
meeting, as did the Vice Chair of the Independent Monitoring Board (IMB) and
officials of the Prison Officers’ Association. During three follow up visits, 16 members
of staff, including the Safer Custody Manager, the Governor, two Chaplains, a
member of the Independent Monitoring Board, two doctors, the Healthcare Centre
Manager, one prisoner, prison officers and nurses were interviewed individually. All
gave their time and information willingly, for which my investigators remain extremely
grateful. The Manchester branch of the Prison Officers’ Association lent their ready
support and facilitated greatly the work of the investigation.
9. Greater Manchester Police shared their information and findings. I am grateful for
their cooperation.
10. One of my investigators and one of my Family Liaison Officers met the man’s father
and brother at their home. They were made most welcome. The information the
family provided contributed a great deal to the investigation. The man’s father also
asked my investigators to place on record his grateful thanks for the compassionate
and personal help he had received and continues to receive from the Governor,
Chaplains and Healthcare Manager at Manchester. The man’s father thought that his
son had been treated well at Manchester. However, he wanted to know how his son
had acquired the bootlace which was used as a ligature. I have reflected on this, and
highlighted his questions, in the body of my report.
11. The North Manchester Primary Care Trust arranged a clinical review of the man’s
healthcare management at Manchester. The review also made a significant
contribution to the investigation.
.
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HM Prison Manchester
12. Manchester holds prisoners remanded into custody from the Greater Manchester
area. The prison was rebuilt following a major disturbance in 1990 and now forms
part of the Prison Service’s high security estate. At the time of my investigation it held
1245 prisoners.
13. Manchester was market tested, for the second time, in year 2000 and as a result of
its success, was awarded a 10 year Service Level Agreement, commencing on 16
October 2001. The Service Level Agreement mirrors the format of commercial
contracts held by private prisons. A key principle is that performance delivery carries
financial risk.
14. HM Chief Inspector of Prisons, in her report of a July 2004 inspection, said that the
prison’s arrangements for suicide and self-harm risk were good with all staff alert,
aware and properly trained. The safer custody meetings were regular and well-
attended by staff, outside representatives and prisoners. Reviews of those at risk
were held on time and documentation was of reasonable quality. However, the Chief
Inspector’s report said that information from reviews did not always find its way into
support plans for prisoners. The report noted that anti-bullying arrangements were
not good, but this had been recognised by the prison which had appointed a Principal
Officer whose work was to bring the anti-bullying strategy and practice to a good
standard.
15. There were three apparently self-inflicted deaths at Manchester in 2003, and in 2004
there were six. In November 2004, new systems for staff awareness, together with a
comprehensive re-training programme were put into place.
16. Two years after the inspection, Manchester has continued its development and has
brought anti-bullying and suicide and self-harm prevention under one umbrella.
Further progress has been made and at the time of my investigation, the policy was
well-publicised around the prison. Notices on residential notice boards give details of
suicide prevention arrangements and how prisoners can contact Listeners (prisoners
trained by Samaritans) and Samaritans. The Safer Custody Meeting meets monthly
and has a very high profile, being chaired by the Deputy Governor.
17. My investigators found that the Governor and his staff are well-trained, caring and
keen to discharge their duties in respect of suicide and self-harm risk. There is a
clearly identifiable atmosphere of care and compassion at the prison. My
investigators also sensed a clear sense of direction and found active cooperation
between staff, prisoners and community groups.
18. In summary, Manchester is a busy and complex local prison. Many of its prisoners
have special medical and psychiatric needs and the Healthcare Centre is always fully
occupied. It usually has a waiting list for admissions. It is against this backdrop that
the prison should be seen.
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Events leading up to the man’s death
19. This man arrived at Manchester prison on 7 September. He told staff that he was
depressed, and that he was withdrawing from heroin, and gave details of his previous
medical and psychiatric treatment in the community. Nursing staff in the induction
wing in Manchester immediately telephoned Bolton, Salford and Trafford NHS
Primary Care Trust (PCT) and spoke to a Criminal Justice Drug Worker, who had
personally treated the man as late as 19 August 2005. The prison was given
background information in respect of his mental health. The drug worker also agreed
to fax notes to Manchester and sent them the following day. Staff at Manchester
conducted a risk assessment and located the man in the induction wing, sharing a
cell with another prisoner. Reception staff alerted the Healthcare Centre to their
anxiety about the man and, although he did not say he had thoughts of harming
himself, they considered the warning signals were clear. A special file known as
‘Care of at risk prisoners’, sub-headed ‘Assessment, Care in Custody and Teamwork’
(ACCT) was opened. In practical terms, this meant that the man should be observed
frequently - three times during the core day and four or five times during the night. A
further review was programmed for the next day, 8 September.
20. On 8 September, the man attended an assessment interview under the ACCT
programme. During the interview, and in the follow-up action plan, it was noted that
he had drug addiction problems and that, although he said he had no intention of self-
harming, things could change. The case manager noted that the man was to see a
member of the In reach Mental Health Team that day - and later the psychiatrist. A
further review was scheduled for one week’s time and the ACCT plan remained in
place.
21. The man saw a Registered Mental Nurse (RMN) of the Mental Health In-reach Team.
The man had tested positive for a number of drugs. The nurse noted that the man
said he was hearing voices and that he felt like harming himself and others. She
arranged for him to see the psychiatrist, the following day. The criminal justice drugs
worker had by now sent records of the man’s treatment and history in the community,
and a picture of his healthcare considerations was becoming increasingly clear.
22. The psychiatrist saw the man the following day. The psychiatrist noted, in a full
record of his assessment, a provisional diagnosis of depression and schizophrenia
and he prescribed medication. He also noted that the man said he felt ‘ok in the wing
as another prisoner is looking after him.’ A further appointment was made for 14
September. On 12 September, another RMN saw him and observed him as being
more settled and ‘much brighter’. She noted that the man was due in court on the 14
September (the day set for a further psychiatric consultation) and rearranged the
appointment for the following day. The nurse also spoke by telephone to another
member of the PCT, who also had detailed knowledge of the man and learned details
of his previous treatment at a nearby hospital. Further clinical records were faxed
from the PCT the same day.
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23. On 14 September, the man again appeared in court for a pre-trial hearing. The court
ordered him to appear for trial at the Crown Court, date not specified, and to be
remanded in custody at Manchester until his trial. He returned to his cell in the
induction wing of the prison, this time with a new cellmate. An officer spoke to him.
The man said he was ‘fine’ but ‘appeared reluctant to engage in conversation’. The
officer reminded him of the Listeners arrangements and the Samaritans confidential
telephone. At 11.35pm, the man was sitting at his table. Asked if everything was
okay, he replied yes. The night passed uneventfully and he appeared to have slept
until 7am next morning.
24. The man’s psychiatric appointment went ahead as planned on 15 September. The
psychiatrist was concerned as the man told him he was hearing voices telling him to
kill himself or somebody else. He also said that he had not slept well for a few nights.
The psychiatrist admitted the man to the Healthcare Centre as an inpatient and
directed an ‘intermittent watch’. The second case review under the ACCT
arrangements was held the same day. The man attended the review. The case
manager noted that this man’s care had been taken over within the Healthcare
Centre, and that he had thoughts of ‘self-harming but has no inclination to carry them
out’. The man was seen again later that day by another RMN who completed an
assessment and agreed a care plan with him.
25. On 19 September the man was seen by a RMN he had met before. She noted that
the man appeared settled and he said he was eating well and sleeping better. In a
consultation later that day, the man told the psychiatrist, who had treated him
continuously since his arrival at Manchester, that things had not changed much and
he was still hearing voices and felt like harming himself. The psychiatrist modified the
man’s medication and arranged to see him within 48 hours.
26. A fellow prisoner who worked in the Healthcare Centre, told my investigators that the
man had said to him, on 20 September, that he might well face a charge of murder in
connection with ‘someone’s’ death and that he was worried and uncertain about the
way his court proceedings would evolve. He gave no detail of a victim. The prisoner
assumed that the man was referring to a crime involving another man.
27. On 21 September the man again saw the psychiatrist. A nurse was present. Both
doctor and nurse saw a dramatic change for the better. The man had just returned
from a visit with his solicitor. He told the psychiatrist that the charges he faced in
connection with the death of his mother were less serious than he had feared. He
said he thought the police had been contemplating a charge of murder, but his
solicitor had assured him that this was not the case. The psychiatrist noted that the
man said he was still hearing voices but did not express any suicidal thoughts. The
nurse, who had seen the man a day earlier, told my investigators that it was like
seeing a different man. It was as if ‘a load had been lightened’. She remembered
the psychiatrist asking about self-harm and the man saying he was not feeling
suicidal. Later, in interview with my investigators, the psychiatrist said that the
change for the better in his patient was the best he had seen in many years of
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practising psychiatry. The psychiatrist made a comprehensive note in the man’s
medical notes to the effect that he was much better. He made a note also in the
ACCT file, ‘Seen and assessed. Stop intermittent watch. Continue anti-ligature cell.’
Both records were returned to the administration office within the Healthcare Centre.
28. It is clear from the psychiatrist note that he thought the man was already located in an
anti-ligature cell. However, he was not located in an anti-ligature cell. He returned to
his own cell. Moreover, although the psychiatrist made a note on the ACCT form in
respect of anti-ligature cell, he did not make one on the main medical record. The
Healthcare Manager told my investigator she did not know of the instruction. The cell
that the man was located in had previously been designated ‘anti-ligature’, but no
longer met the standard. The anti-ligature cells were fully occupied. It would have
been better if entries had been made in the ACCT documentation and in the man’s
medical record.
The Governor should remind staff of the importance of ensuring that important
information is cross-referenced between records and that staff ensure they read
all the papers relating to a particular case.
29. Between 7pm on the evening of 21 September and 9am next morning, nine separate
entries appear in the mans’ ACCT record. The man attended the ‘Chaplain’s Hour’
meeting where he was assessed as sitting quietly at the back of the group but ‘does
appear to be following proceedings’. At the end of the evening, he appears to have
dropped to sleep watching television at 11.50pm and then throughout the night slept
in bed. The last entry, at 9am next morning reads ‘Status ok. Sat on bed.’
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Events following the death
30. At about 9.50am, a nurse started her rounds as was her custom, checking on
patients in the Healthcare Centre. She went to the man’s cell, looked through the
observation panel and saw him hanging from a ligature around his neck, attached to
the cell bars. The nurse does not carry a cell key, but the office was immediately
opposite the man’s cell and she went in, calling for assistance. The senior healthcare
officer was working in there and together they went into the man’s cell. They called
for further assistance. A RMN on duty pressed the alarm bell. Manchester’s
emergency plan was activated and the incident log provides a detailed timetable of
subsequent events. An ambulance was called at 9.56am. The nurse was sent for
the ‘suicide box’. At 9.55am, an officer who was by that time in the cell, assisted the
senior healthcare officer and nurse to cut the ligature, a black bootlace, and they
started resuscitation procedures. Despite using two sets of protective mouth
equipment, the nurse had to break off twice to clean out her own mouth. The on call
doctor for the prison arrived at 10am and the team continued to try to revive the man.
They established an airway and noted the defibrillator instruction not to apply shock
treatment but to continue with resuscitation.
The nurse should be commended by the Governor. She was distressed as she
knew the man and thought he was over the worst. Nevertheless she performed
superbly well in her response to these sad events and particularly in the
resuscitation process. The work was difficult and unpleasant but she had no
regard for herself. This was commitment of the highest order, in the best
traditions of the Prison Service.
31. Paramedics arrived at the prison at 10.05am and the prison doctor, in consultation
with them, pronounced the man dead at 10.09am. In accordance with emergency
procedures, the man’s cell was sealed to await the arrival of the coroner’s officer and
police.
32. The duty chaplain, was paged at 10am and he also went to the man’s cell. He was
there within a few minutes, but by that time the man was dead. At 12 midday, the
Healthcare Centre Manager, a police officer, and chaplain visited the man’s father at
his home. Together they broke the news. The chaplain and his colleague
accompanied the man’s father that evening to the infirmary in order that he might
formally identify his son’s body. In five or six further visits and telephone calls, the
chaplains helped the father to make arrangements for his son’s funeral. They gave
him a letter of sympathy from the Governor and they paid funeral expenses on his
behalf. Some days later they conducted the funeral service at the family’s request.
All of the man’s family remain deeply grateful to them for the care and support which
they continue to receive from the chaplains.
33. On the same day this man died, a governor grade conducted a review meeting. This
was in order to establish whether or not they had done all they could and to examine,
while things were fresh in their minds, if there were lessons to be learnt. Sixteen
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members of staff attended, including two members of the Care Team. The notes are
clear, concise and an example of good practice within the Prison Service. Care
Team members subsequently contacted all staff who had been involved in the sad
circumstances of this death.
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Clinical review
34. In the clinical review completed on 2 November 2005, it was found that the man’s
contacts with individual clinicians at HMP Manchester were timely and well
documented, and that he had cooperated fully with his assessments and treatment.
Such variations as were made to his medication were possible because he was
honest throughout in respect of the way he was feeling. Consequently, nurses and
doctors made all decisions with regard to the information available at each
consultation and as a result of observing the man as an inpatient in the Healthcare
Centre.
35. The clinical reviewer observed, ‘There was nothing to indicate at the last psychiatrist’s
review that the man was going to take his own life.’ The review found that
resuscitation procedures were conducted appropriately by staff and she noted that
they were supervised between 10am and 10.09am by the prison doctor.
36. Finally, the review recommended that reviews and decisions in respect of patients
subject to suicide and self-harm procedures should be taken by the multi-disciplinary
team and not an individual clinician. The decision to stop the man’s ‘intermittent
watch’ was taken by the psychiatrist alone on the 21 September.
Decisions to vary the conditions of a suicide and self-harm programme under
ACCT should be taken by the full review team.
37. The review noted one example of good practice: ‘The lead nurse for Dual Diagnosis
and the RMN on duty at the time of the man’s admission can be complimented for
their comprehensive and clearly written records.’
The RMN and RGN should be commended by the Governor and Senior Medical
Officer for the high quality, clarity and comprehensive recording of their
contributions to the man’s care.
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Conclusions
38. The man was mentally ill for many years before being sent to prison for the first time
on 7 September. He was bound to find prison life difficult and the circumstances in
which he was sent there were highly unusual. He was charged with offences, in
themselves serious enough. But at the time of his remand into custody, there was
the possibility in his own mind that even more serious charges were being
considered.
39. Reception and induction staff at Manchester carefully and accurately assessed his
condition. In a commendable display of teamwork, the discipline and healthcare
professionals in prison and in the community identified his needs and ensured they
were met. Manchester staff contacted healthcare workers who knew him in the
community and put in place a comprehensive management plan to help him through
his early days in prison. He went into a shared cell with someone he knew, and risk
assessments and actions arising from them were complete and accurate. Within a
day or so, written details of previous diagnoses and treatments arrived from the PCT,
and within five days a comprehensive psychiatric history was also to hand.
40. The medical and nursing care provided for the man was excellent. In the fortnight he
was in Manchester, he was assessed formally on four occasions by the same
psychiatrist, and was interviewed and counselled on at least as many occasions by
skilled healthcare professionals. Discipline staff played their part and their entries in
self-harm documentation were full and well-observed. The standard of care within
the main induction centre and in the healthcare centre is considered to have been
excellent.
41. While the decision by the psychiatrist to discontinue the intermittent watch on the man
does not appear justified by subsequent events, given the nature of his last
consultation with him (and the evidence of the nurse, it seems likely that a multi-
disciplinary review panel would have come to the same conclusion.
42. It is regrettable that the instruction in respect of the psychiatrists implicit belief that the
man was in an anti-ligature cell, an arrangement which he said should continue, was
not cross-referenced from the ACCT form to the medical record. The Healthcare
Centre Manager told my investigator that she did not know of the instruction. In any
case, the anti-ligature cells were occupied by prisoners who had greater needs.
Nevertheless, the instruction should have been clear in both records.
43. The day before he died, the man wrote to his father, saying ‘I am not too good at the
moment, the psychiatrist has increased my medication but don’t worry, I’ll bounce
back.’ He went on to say that he was to see his solicitor that day (the visit after which
he told the psychiatrist about that serious charges against him were not to be
pursued) and that he was looking forward to a ‘canteen pack’ (food, tobacco, sweets
etc). He ended the letter by saying, ‘Please write to me soon. I’ll look forward to
hearing from you.’ Given the tone of that letter and the later news from his solicitor, it
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seems reasonable to believe that he, if not on top form, was coping well enough
given the circumstances in which he found himself.
44. It has not been possible to establish how the man acquired the bootlace. Police
searched the cells adjacent to the one in which the man died and found no evidence
of his having acquired it from within that area. My investigator examined
Manchester’s Service Level Agreement in respect of searching requirements. All
targets had been met, including, significantly, those relating to the Healthcare Centre.
It is known that the man had asked for a change of clothes shortly before he died. He
may have changed his clothes or he may not. Records of such routine matters are
not kept. In any case, the healthcare store holds only basic items of clothing and
laces are not kept there.
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Recommendations
1. The Governor should remind staff of the importance of ensuring that important
information is cross-referenced between records and that staff ensure they read
all the papers relating to a particular case.
2. The nurse administering CPR should be commended by the Governor. She was
distressed as she knew the man and thought he was over the worst.
Nevertheless she performed superbly well in her response to these sad events
and particularly in the resuscitation process. The work was difficult and
unpleasant but she had no regard for herself. This was commitment of the
highest order, in the best traditions of the Prison Service.
3. Decisions to vary the conditions of a suicide and self-harm programme under
ACCT should be taken by the full review team.
4. The two RMN should be commended by the Governor and Senior Medical Officer
for the high quality, clarity and comprehensive recording of their contributions to
the man’s care.
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Good practice
1. Cooperation between prison and PCT was excellent. Oral and documented
information was comprehensive and conducted quickly and without fuss.
This is clear evidence of a true partnership between services.
2. Record keeping at Manchester was excellent at all levels with staff sharing
information willingly. Notes were full, comprehensive and provide evidence
of good training and understanding of the importance of good
documentation.
3. Co-operation between Manchester prison and Greater Manchester Police was
excellent. Documents were freely exchanged and my investigators had
access to all they required. Police, during their formal interviews, asked each
person interviewed to indicate if they agreed to release to my investigators
records of their interview notes. All agreed and the documents were released
at our first visit.
4. The post-incident de-brief was held immediately. It was well chaired by a
governor grade it was well attended and comprehensively minuted. The
notes of the meeting were used to review and improve Manchester’s
contingency plans.
5. Manchester’s care team saw all staff involved. They systematically and
purposefully made sure that those who needed help received it and that
others were coping with their shock and sense of loss at the death.
6. The two Chaplains performed their tasks to a standard well above and
beyond the call of duty. The support they gave to the man’s father and his
family, the conduit they provided between him and the prison and their
eventual conducting of the man’s funeral service are together evidence of
commitment of the highest order.
7. The Chaplains, The Healthcare Manager, and Detective Chief Inspector of
Greater Manchester Police, are to be congratulated on the sensitive way in
which they worked together to bring sad news of the death to the man’s
father when they visited him at his home.
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