Coroner: profound changes have been made to services as a result of problems found in the events running up to Richard’s death At this time I offer my condolences to Richard’s family and those close to him on the loss of someone who clearly brought joy into so many lives.

Coroner: profound changes have been made to services as a result of problems found in the events running up to Richard’s death At this time I offer my condolences to Richard’s family and those close to him on the loss of someone who clearly brought joy into so many lives.