Introduction
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| This
chapter
describes
the
arrangements
in
the
North
Manchester
Coroner's
office
in
1987,
the
staff
involved
and
the
procedures
in
place
for
investigation
of
sudden
deaths
in
the
community.
Later
paragraphs
set
out
what
happened
in
preparation
for
and
at
the
inquest
into
Mr
Isaacs'
death.
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|
Sources
of
information
|
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|
| The
recollections
of
the
Coroner,
the
Coroner's
Officers
and
staff
of
the
Coroner's
office.
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|
| The
Coroner
and
his
office
in
1987
|
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| Her
Majesty's
Coroner
for
the
North
Manchester
jurisdiction
was
Mr
Bryan
North,
who
had
been
appointed
in
1978.
Mr
North
had
previously
served
as
Deputy
Coroner
for
Lancashire
from
1965
until
the
local
government
reorganisation
of
1974
when
he
was
appointed
Coroner
for
Oldham.
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|
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|
| Mr
North's
jurisdiction
covered
the
boroughs
of
Oldham
and
Rochdale
in
addition
to
Bury,
which
included
Prestwich
and
Whitefield
districts.
By
agreement
between
the
three
boroughs,
Rochdale
Council
took
the
lead
in
providing
financial
and
administrative
support
for
the
Coroner
as
the
Coroner's
office
is
located
in
Rochdale.
Mr
North's
office
staff
were
employed
by
Rochdale
Council.
In
1987,
in
order
of
seniority,
Mr
North's
office
staff
were
Mrs
Joyce
Langan,
Mrs
Shirley
Connolly
and
Mrs
Gillian
Williamson.
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| Coroner's
Officers |
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| In
each
of
the
three
boroughs
a
police
officer
served
as
Coroner's
Officer.
PC Joe Cassells
was
Coroner's
Officer
for
Bury,
where
he
was
responsible
for
investigation
of
deceased
persons
whose
bodies
were
taken
to
the
mortuaries
in
Bury
and
Prestwich.
PC
David
Rigg
and
PC
David
Harrison
were,
respectively,
Coroner's
Officers
for
the
Rochdale
and
Oldham
boroughs.
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| The
Coroner's
Officers
would
generally,
but
not
invariably,
attend
the
start
of
a
post
mortem
examination
ordered
by
the
Coroner,
in
order
to
identify
the
deceased
to
the
pathologist.
Thereafter
the
practice
of
the
Coroner's
Officers
varied.
In
Rochdale,
PC Rigg
would
almost
always
attend
for
the
whole
of
the
post
mortem
procedure.
PC Cassells
attended
the
vast
majority
of
post
mortems
at
Fairfield
Hospital
and
usually,
but
not
always,
remained
until
the
end
of
the
examination.
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| After
post
mortems
at
Fairfield,
PC
Cassells
would
generally
telephone
or
visit
the
family
of
the
deceased
to
inform
them
of
the
cause
of
death
and
of
arrangements
for
obtaining
the
death
certificate.
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| PC
Cassells
attended
only
a
few
of
the
post
mortems
at
Prestwich
mortuary
as
the
arrangements
for
examinations
there
were
different.
Dr
Farrand
would
telephone
the
Coroner's
office
to
inform
the
Coroner
of
the
cause
of
death
and
the
Coroner's
office
staff
would
communicate
with
the
relatives.
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| In
all
mortuaries
where
the
Coroner's
Officers
had
not
been
involved
in
removal
of
the
body
to
the
mortuary,
the
police
officer
who
had
attended
the
scene
of
death
would
attend
to
identify
the
body
to
the
pathologist.
In
the
case
of
Mr
Isaacs,
identification
of
the
body
to
Dr
Farrand
was
WPC
Rigby's
responsibility.
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|
Investigation
of
sudden
deaths
in
the
community
|
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| 1. Deaths
with
no
suspicious
circumstances
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| |
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| When
a
sudden
death
was
reported
to
the
Coroner
and
there
were
no
suspicious
circumstances,
an
urgent
responsibility
of
the
Coroner's
Officer
or
office
staff
was
to
contact
the
deceased's
general
practitioner
or
other
recent
medical
attendant
to
ask
if
he
was
in
a
position
to
issue
a
death
certificate.
Where
pre-existing
disease
was
known
to
the
doctor
and
a
death
certificate
could
be
issued,
there
would
then
be
no
need
for
the
Coroner
to
order
a
post-mortem
examination.
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| 2. Deaths
in
suspicious
circumstances
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| In
all
deaths
in
suspicious
circumstances,
investigations
are
undertaken
by
the
police
who
report
their
findings
to
the
Coroner.
A
post
mortem
will
invariably
follow.
In
such
cases
the
Coroner,
after
discussion
with
the
police,
will
decide
on
the
pathologist
to
carry
out
the
post
mortem
examination.
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Release
of
body
|
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| Where
there
are
no
suspicious
circumstances,
the
body
of
the
deceased
can
be
released
to
the
relatives
once
the
Coroner
is
satisfied
about
the
cause
of
death.
The
pathologist
will
normally
convey
his
findings
by
telephone
to
the
Coroner's
office,
to
allow
early
release
of
the
body.
The
written
report
will
follow
in
time
for
the
inquest.
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Collection
of
evidence
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| It
is
the
duty
of
the
Coroner's
Officers
to
interview
witnesses,
obtain
statements
from
them
for
the
Coroner
and
bring
together
other
evidence
that
the
Coroner
might
wish
to
consider
before
or
during
the
inquest.
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| In
preparation
for
the
inquest
into
the
death
of
Mr
Isaacs,
statements
were
obtained
from:
|
|
|
|
- WPC
Sharon
Rigby;
|
Annex
9
|
- Mrs
Isaacs,
his
widow;
|
Annex
10
|
- the
late
Mr
Clive
Lingard,
who
had
found
Mr
Isaacs'
body;
|
Annex
11
|
- Dr
Rosenberg,
Mr
Isaacs'
general
practitioner.
|
Annex
12
|
|
|
|
No
other
statements
were
obtained
for
the
inquest
but
Dr
Farrand's
written
report
on
his
findings
at
the
post
mortem
was
available
to
the
Coroner.
The
report
did
not
record
that
Mr
Isaacs'
brain
had
been
retained
at
the
end
of
the
post
mortem
examination.
|
Annex
13
|
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|
The
resumed
inquest
|
|
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| On
16
March
the
Coroner,
Mr
North,
reopened
the
inquest,
which
had
been
adjourned
after
evidence
of
identification
had
been
heard
on
27
February.
Mr
North,
sitting
without
a
jury,
considered
the
written
documents
listed
above.
The
record
of
the
inquisition
does
not
refer
to
other
exhibits
or
documents
entered
as
exhibits.
Although
in
some
cases
of
sudden
death
police
photographs
were
taken
of
the
scene,
there
is
no
record
of
any
photographs
being
among
the
exhibits
submitted
to
the
Coroner.
|
Annex
14
|
|
|
| The
resumed
inquest
was
attended
by
Mrs
Isaacs.
She
was
represented
by
a
solicitor
and
a
barrister
who
asked
a
number
of
questions
on
her
behalf.
Mr
Lingard
and
WPC Rigby
attended
the
inquest
to
give
oral
evidence,
but
Dr
Rosenberg
and
Dr Farrand
did
not.
Dr
Rosenberg's
statement
and
Dr
Farrand's
report
were
part
of
the
evidence
considered
by
the
Coroner.
|
|
|
|
| After
considering
the
written
and
oral
evidence
as
presented
to
him,
the
Coroner
summed
up
and
recorded
a
verdict
of
'Suicide'.
The
inquisition
records
the
cause
of
death
as
'Hanging'
and
that
'Cyril
Mark
Isaacs
died
of
the
aforesaid
at
his
home.
He
was
found
hanging
from
the
loft
by
an
electric
flex'.
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|
Immediate
aftermath
to
the
inquest
|
|
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|
| Mrs
Isaacs
and
the
family
were
devastated
by
the
verdict.
The
stigma
of
suicide
has
profound
implications
to
those
of
the
Jewish
faith
and
was
to
become
an
intolerable
burden
to
the
family.
|
|
|
|
| Until
the
inquest,
Mrs
Isaacs
was
unaware
of
the
contents
of
the
statements
submitted
in
evidence
to
the
Coroner.
In
particular
she
was
dismayed
that,
apart
from
her
own
statement,
the
Coroner
had
been
told
very
little
about
the
severity
of
Mr
Isaacs'
depression
and
other
mental
health
problems.
Mrs
Isaacs
had
expected
her
husband's
mental
health,
about
which
he
had
consulted
a
number
of
doctors
in
the
last
weeks
of
his
life,
would
be
fully
described
in
Dr
Rosenberg's
witness
statement.
|
Annex
12
|
|
|
| Mrs
Isaacs
believed
that,
if
the
Coroner
had
been
fully
informed
of
the
extent
of
the
Mr
Isaacs'
severe
mental
health
problems
and
the
medical
care
he
had
received
prior
to
his
death,
the
verdict
would
have
been
different.
|
|
|
|
The
return
of
the
kettle
flex
|
|
|
|
| Some
days
after
the
inquest
the
police
called
to
return
'property'
to
Mrs
Isaacs.
This
property
included
medicines
and
the
kettle
flex
which
Mr
Isaacs
had
used
to
cause
his
death.
Mrs
Isaacs
has
a
receipt
for
the
return
of
the
medication
dated
16
March
1987.
This
receipt
does
not
refer
to
the
kettle
flex.
|
|
The
police
records
of
the
case
do
not
refer
to
this
incident,
but
police
practice
at
the
time
was
only
to
return
property
involved
in
an
unnatural
death
when
this
was
requested.
Mrs
Isaacs
and
the
family
had
certainly
not
asked
for
the
flex
to
be
returned.
Mr
Isaacs'
clothes
and
personal
effects
had
already
been
returned
within
days
of
his
death.
|
|
|
|
| The
police
property
book
in
which
the
flex
might
have
been
recorded
was
destroyed
several
years
ago
in
keeping
with
standard
time
limits
on
such
documents.
The
definitive
explanation
for
the
return
of
the
flex
cannot
be
given.
However,
the
police
have
told
me
that
it
is
possible
that
a
person
representing
Mrs
Isaacs
at
the
inquest
was
asked
about
the
return
of
Mr
Isaacs'
property,
as
it
was
not
the
practice
to
approach
the
relatives
direct.
Without
realising
that
the
'property'
in
question
was
the
means
of
Mr
Isaacs'
death,
the
reply
given
could
have
indicated
that
all
property
should
be
returned.
Whatever
was
the
explanation,
the
return
of
the
flex
was
to
cause
unnecessary
and
avoidable
distress
to
Mrs
Isaacs.
|
|
|
|
| Contact
with
official
agencies |
|
|
|
| In
the
interval
between
Mr
Isaacs'
death
and
the
inquest,
the
police
were
in
contact
with
Mr
Isaacs'
family
but
no
other
official
agency
was
involved.
|
|
|
|
| Correspondence
with
the
Coroner
1987-1991 |
|
|
|
| On
23
March
1987
Mrs
Isaacs
wrote
the
first
of
many
letters(1)
to
the
Coroner
requesting
that
he
reconsider
matters
that
had
not
been
presented
to
him
during
the
inquest.
In
his
reply
the
Coroner
emphasised
that
his
verdict
had
been
based
on
the
evidence
presented
at
the
time
of
the
inquisition.
|
|
|
|
| Mrs
Isaacs'
correspondence
with
the
Coroner
continued
until
1991.
In
her
letters
to
the
Coroner
and
to
other
authorities
to
whom
she
wrote
challenging
the
verdict,
Mrs Isaacs
drew
attention
to
aspects
of
Mr
Isaacs'
mental
health
that
had
not
been
included
in
the
evidence
presented
at
the
inquest.
|
|
|
|
Discovery
that
Mr
Isaacs'
brain
had
been
retained
|
|
|
|
| On
5
April
2000,
Mrs
Isaacs
was
reviewing
papers
relating
to
the
medical
care
of
her
husband,
among
which
were
some
papers
which
Mrs
Isaacs
had
not
previously
seen.
The
papers
included
an
undated
letter
sent
from
the
Department
of
Psychiatry
at
Manchester
University
to
Dr
Rosenberg,
Mr
Isaacs'
general
practitioner.
The
letter,
reproduced
at
Annex
15,
informed
Dr
Rosenberg
that
the
University
had
collected
samples
of
Mr
Isaacs'
brain
and
asked
a
number
of
questions
about
Mr
Isaacs'
mental
health
and
medication
prior
to
his
death.
|
Annex
15
|
|
|
| Mrs
Isaacs
and
her
family
were
greatly
shocked
by
this
discovery.
It
was
an
affront
to
Mr
Isaacs'
religious
beliefs
and
those
of
his
family.
Mrs
Isaacs
immediately
began
to
investigate
why
and
how
her
husband's
brain
had
been
retained.
This
investigation
is
the
direct
result
of
the
questions
that
Mrs
Isaacs
has
asked.
|
|
|
|
Relevance
of
the
evidence
presented
at
the
inquest
to
this
investigation
|
|
|
|
| While
Mrs
Isaacs'
concerns
about
the
inquest
verdict,
and
other
legal
and
financial
aspects
of
the
inquest
on
her
husband,
are
specifically
excluded
from
consideration
in
this
investigation,
the
availability
and
presentation
of
relevant
evidence
at
inquests
is
directly
relevant
to
the
fourth
of
my
Terms
of
Reference.
This
is
further
considered
in
Chapter
43.
|
|
|
|
Matters
in
Chapter
2
that
are
developed
in
other
chapters
|
|
|
|
Can
more
be
done
when
a
sudden
death
occurs
in
the
community
to
ensure
that
the
relatives
are
kept
informed
of
what
is
to
happen
and
why?
In
particular,
when
the
relatives
are
firmly
opposed
to
a
post
mortem
for
religious
or
other
reason,
what
steps
can
be
taken
to
explain
to
them
why
one
is
necessary
and
to
respond
to
their
concerns?
Chapter
45.
|
|
| Is
it
possible
to
modify
the
necessary
investigative
procedures
of
sudden
death
without
prejudice
to
their
effectiveness,
in
order
better
to
accommodate
the
religious
beliefs
of
the
deceased
and
his/her
relatives?
Chapter
43.
|
|
|
|
| Where
there
are
no
suspicious
circumstances
in
a
case
of
sudden
death
in
the
community,
steps
should
be
taken
to
find
out
if
the
deceased's
general
practitioner,
or
other
recent
medical
attendant,
is
in
a
position
to
certify
the
cause
of
death
before
a
Coroner's
autopsy
is
ordered,
Chapter
43.
|
|
|
|
Can
more
be
done
to
ensure
that
all
relevant
medical
factors
are
presented
in
evidence
to
the
Coroner?
Chapter
43.
|
|
| The
importance
of
recording
the
retention
of
any
organs
and/or
tissues
in
the
pathology
report
sent
to
the
Coroner,
Chapter
35.
|
|
|
|
| The
letter
to
Dr
Rosenberg
asking
for
information
about
Mr
Isaacs'
mental
health,
Chapters
6,
18
and
20.
|
|
|
|
| Summary |
|
|
|
| The
inquest
into
Mr
Isaacs'
death
took
place
on
16
March
1987.
|
|
|
|
| Mr
Isaacs'
previous
mental
health
difficulties
received
little
attention
in
the
statement
provided
by
Dr
Rosenberg.
|
|
|
|
| A
verdict
of
hanging
was
recorded. |
|
|
|
| Mrs
Isaacs
in
correspondence
to
the
Coroner
drew
attention
to
Mr
Isaacs'
mental
health
problems.
This
correspondence
continued
for
four
years.
|
|
|
|
| Mrs
Isaacs'
distress
was
added
to
when
the
police
returned
the
kettle
flex
to
her.
This
was
the
flex
from
which
Mr
Isaacs
had
been
suspended.
The
reasons
for
returning
the
flex
have
not
been
explained.
The
practice
of
the
police
returning
objects
of
this
kind
should,
in
my
view,
be
reconsidered.
|
|
|
|
| The
police
were
the
only
official
agency
in
contact
with
Mr
Isaacs'
family
during
a
time
of
great
distress.
|
|
|
|
| References |
|
|
|
|
1 Correspondence
between
Mrs
Isaacs
and
the
Coroner.
|
|
