"The laryngeal structures: There was evidence of haemorrhage with a small amount of bruising in the tissues around the superior thyroid cartilage, and there was bruising around the right thyroid gland. The larynx itself showed congestion with some petechiae. No obvious fracture of the bones was identified."
"The findings here are of an "asphyxial" death - in particular evidenced by the conjunctival petechiae and bleeding into the ear. Other positive findings include haemorrhage with bruising around the thyroid cartilage and gland with laryngeal congestion and petechiae. There is also evidence of bruising to the muscles over the back of the body. This death falls into the category of death occurring as a result of respiratory impairment/restriction during restraint leading to asphyxia. In this case there is evidence that airway occlusion arose due to pressure to the neck (as evidenced by the internal findings). In addition, restriction of chest movement whilst on the ground with pressure applied to the back of the chest would occur. Apart from these asphyxia can occur as a result of being in the prone position i.e. when carried face down. This appears to be due to interference with the breathing process itself causing decreased respiratory movement and/or compromise to the airway. Thus, in this case there is likely to have been a combination of mechanisms leading to asphyxia. Physical/emotional exertion as in the fight/flight situation is also likely to have occurred exacerbating the effects of respiratory restriction. The deceased had evidence of narrowing to one of the arteries supplying the heart muscle. This could also have played a role ... In terms of other injury these are in themselves of a relatively minor type and consistent with a struggle situation. They have not caused or contributed to death."
"The only conclusion that it was possible for the Jury to reach was that Brumby was lying about this suspicion."
"6.1 Despite a detailed statement, and extensive examination at the inquest, it is still not clear exactly what physical mechanism led to Mr Manning's death. Despite the inability of Dr Whitwell to specify the precise cause of death, it is my view that this would not present any great difficulty in the event of a criminal trial. I have no doubt that a jury could properly reach the view that Mr Manning died because the way in which he was restrained/carried from his cell to the servery area prevented him from breathing. On that basis I do not consider that the difficulties in attributing specific medical reasons for death would present any significant obstacle to a successful prosecution." "8.3 The evidence of the cause of death while uncertain in medical terms appears to be quite clear in lay terms and is entirely consistent with the inmate evidence of an arm being across the deceased's throat. The time taken during the course of the carrying can be no more than five minutes, and it does not appear as though any indication was given by the deceased himself, or by others that there may have been some interference with his breathing processes."
"The conduct of the Officers when escorting Mr Manning from his cell towards the Segregation Unit of the Prison would be subject to the prison rules concerning the use of violence. On all of the available evidence the prisoner was very violent and difficult to control and therefore much force was needed in order to transport him. Wrist locks had been applied in the approved Home Office method and a head restraint had been applied to the Deceased. There are differing accounts over whether or not that head restraint was carried out in approved Home Office fashion, or whether it was more in the nature of a "neck lock"
"During her evidence to the Inquest she gave an account of observing at all times and ensuring that Nicholson had got a proper restraint on the deceased and that the deceased had never got into a choking position. She confirmed in her evidence that Manning's head was always properly held. If such had been the case then it seems reasonable to assert that Manning would never have died. Accordingly, her testimony cannot be taken as truthful and therefore (even if she is not prosecuted) I do not consider that the Crown would be obliged to call her as part of their case."
"9.2(b) Unlawful Act (Use of Excessive Force) The prospective defendant in this case would be prison officer Nicholson. As I have outlined in the previous paragraph there is a body of evidence in the case which would seem to suggest that at times during the carrying of the deceased prisoner, Mr Nicholson's arm was across the prisoner's throat. It would seem to me that that body of evidence would be sufficient to establish that he would have a case to answer. I must therefore move on to see whether or not I am satisfied that there would be a realistic prospect of conviction in this case. 9.3 The factors in the Prosecution's favour in this case is that the cause of death is entirely consistent with there being an arm across the deceased's throat, or some other physical obstruction which prevented the deceased breathing at the critical times of the carrying. Except in one or two instances the evidence of the other prison officers is silent as to where Nicholson had his hands and arms during the process of the carrying. I anticipate that Nicholson himself would give evidence in accordance with his statement and with the evidence that he gave at Inquest, and that would be to the effect that as far as he was concerned he thought he was applying Home Office approved methods of head retention. It seems to me that the most likely outcome in this case would be that a jury in a criminal trial would be driven to the view that Nicholson's arm or hand had indeed been across the inmate's throat at various times during the violent carrying exercise. There is little in the evidence which would be presented by the Crown which would indicate that such contact was deliberate or indeed continuous. In order to secure a conviction on this basis it would be essential for the Prosecution to show that the excess force being used by Nicholson was a deliberate application of excess force, rather than as a result of attempts to effect a proper restraint which were frustrated by the violence of the struggle. In my view, given all the evidence, there is no realistic prospect that the Crown would be able to establish that this was indeed the case and I therefore take the view that there is no realistic view of conviction of Nicholson of this offence."
"2.7 Counsel said that there would not be a realistic prospect of conviction as the case involved a violent restraint with a struggling prisoner. When the officers realised something was wrong they stopped carrying Manning and tried to help him. Officer Trindle was supervising the restraint and observed no problem with Manning's breathing. 2.8 Counsel advised as such a short period of time had elapsed between the struggle and restraint, there was no issue of gross negligence. The accounts of the eye-witnesses differed remarkably as to what was a short but very violent struggle."
"The descriptions of eye-witnesses, as so often during a short and violent struggle, vary widely and cannot all be correct. Mr Manning met his tragic and untimely death during a violent struggle with prison officers. The principal cause of Mr Manning's death was asphyxiation, the result of a single, or, more likely, a number of factors. It is therefore impossible to say by what act or acts and by whom the asphyxiation was caused, and consequently, it is also impossible to say whether those acts were either unlawful or grossly negligent. We have therefore concluded that there is no realistic prospect of conviction of any prison officer for manslaughter."
"My review was not limited to illegal act manslaughter, but I considered also the possibility of prosecuting certain officers for manslaughter by gross negligence. My review was itself considered in detail by experienced treasury counsel. At the end of my review I considered that there were so many factual inconsistencies in the accounts given by the witnesses whom the Crown would be required to call, and that the medical evidence was so imprecise as to the exact cause of Mr Manning's death, that there was not a realistic prospect of securing a conviction of any person in any criminal proceedings."
"What I was more concerned about, in respect of Unit Manager Nicholson (as will also be seen particularly from paragraph 9.3 of my Review Note) was the question of whether there was a realistic prospect of satisfying a jury, beyond reasonable doubt, that any placing by him of an arm or hand across the throat of Mr Manning was unlawful, in the sense of being a deliberate application of excessive force, rather than the result of attempts to effect a proper restraint, which were frustrated by the violence of the struggle, or even of self-defence. It seemed to me that these were points that would inevitably be taken on behalf of Unit Manager Nicholson if he were to be prosecuted. I foresaw that his defence would be to the effect that he did not knowingly place a hand or arm against Mr Manning's throat, but that if, unwittingly, he had done this in the heat of the struggle it had not, in the particular circumstances, been unlawful. In this regard, it seemed to me that the inconsistencies in the evidence of the various eye-witnesses as to the precise circumstances and manner in which Mr Manning was held and in which a hand or arm came into contact with his neck were likely to present a problem for the prosecution and that the medical evidence could not resolve that problem."
"5.1 Crown Prosecutors must be satisfied that there is enough evidence to provide a "realistic prospect of conviction" against each defendant on each charge. They must consider what the defence case may be and how that is likely to affect the prosecution case. 5.2 A realistic prospect of conviction is an objective test. It means that a jury or bench of magistrates, properly directed in accordance with the law, is more likely than not to convict the defendant of the charge alleged. 5.3 When deciding whether there is enough evidence to prosecute, Crown Prosecutors must consider whether the evidence can be used and is reliable ..."
"It would, of course, be absurd to suggest that in every case the CPS should give reasons for a decision not to prosecute, but there may well be cases where it would be right to do so. I would suggest, for example, that it might be right to do so in those cases where there has been a death in custody, and an inquest jury has returned a verdict of unlawful killing". (Postscript, page 55). He also draws attention to the report of the European Committee for the Prevention of Torture published in January 2000 which at page 20 said: "
"The Crown Prosecution Service, on request, will meet the family of someone killed as a result of a crime, to explain their decision on prosecution."
"In summary, then: (1) there is no general duty to give reasons for a decision, but there are classes of case where there is such a duty. (2) One such class is where the subject matter is an interest so highly regarded by the law (for example, personal liberty), that fairness requires that reasons, at least for particular decisions, be given as of right."