Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in the way the Nursing Home handled a relative’s request for copies of records. We have made recommendations to address this.

The complaint

1. Mr A’s complaint relates to the care of his late mother, Mrs B, by:

• City of Wolverhampton Council (the Council),
• Atholl House Nursing Home (the Nursing Home),
• Royal Wolverhampton Hospital NHS Trust (the Hospital Trust), and
• West Midlands Ambulance Service University NHS Foundation Trust (the Ambulance Trust).

2. Mr A complains about:
1. A decision, following a hospital admission in November 2019, not to allow his mother, Mrs B, to return to a care home she had lived in for several years. Mr A believes the Council were responsible for this decision. He also complains about the Council’s actions and attitude in trying to find an alternative placement.
2. A decision to book two hospital appointments for Mrs B on the same day at the start of the pandemic in March 2020. Mr A also complains about the advice they got to bring Mrs B to the second appointment despite the cancellation of most appointments.
3. Inadequate and faulty heating in Mrs B’s room in the Nursing Home. Mr A said this was evidenced by a heating engineer having stated that someone must have tampered with the radiator in Mrs B’s room.
4. The Nursing Home failing to ensure hospital appointment letters got to Mrs B or her family.
5. The Nursing Home failing to properly administer a mouth ulcer spray to Mrs B as prescribed by a dentist, and then lying in stating that staff had administered it.
6. A failure to provide Mrs B with a Continuous Positive Airway Pressure (CPAP) machine that worked.
7. A failure to explain a text message sent by the Nursing Home to the family on 26 March 2020 which said that residents would be treated in the Nursing Home and not in hospital. Mr A said he still does not know, despite repeatedly asking, where this directive came from.
8. The care and treatment of Mrs B by Nursing Home, Hospital Trust and Ambulance Trust staff between 27 March 2020 and 1 April 2020. Specifically, Mr A complains professionals did not do enough to escalate Mrs B’s care (including a failure to take her to hospital) and did not do enough to address her symptoms.
9. The administration, by Nursing Home staff, of an injection to Mrs B on the night before she died. Mr A queries why the nurse appeared scared. Further, Mr A said the nurse did not explain what impact the injection would have.
10. A failure of the Nursing Home to take sufficient action to limit the chances of Mrs B contracting Covid-19.
11. Concerns about whether Mrs B got Covid-19 and the lack of certainty about this.
12. The way in which professionals verified Mrs B’s death.
13. Avoidable confusion about which Coroner’s office would deal with Mrs B’s case after her death.
14. The failure of the Nursing Home to provide him with copies of its records for Mrs B.

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What I have investigated

3. The courts have confirmed we have discretion to limit the scope of an investigation to key areas only, to be selective about the complaints we will address and identify broad categories and investigate only those. I have limited this investigation to issues (h), (i) and (n). When advising the organisations of the scope of this investigation I described it as follows:

Mr A complains the professionals involved in his mother’s care between 27 March 2020 and 1 April 2020 failed to provide her with appropriate care and treatment. Mr A believes the professionals failed to do enough to diagnose the cause of his mother’s ill health and failed to provide or arrange more intensive support which may have helped his mother survive.

Mr A also complains the Nursing Home and Hospital Trust failed to adequately address his complaints about these matters and failed to properly explain or justify their actions.

Further, Mr A complains the Nursing Home failed to supply him with a copy of his mother’s records despite repeated requests.

4. I have explained why I did not investigate the remainder of Mr A’s concerns in the final section of this statement.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
7. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
8. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
9. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

10. I read the correspondence and supporting evidence Mr B sent to the Ombudsmen and spoke to him on the telephone. I wrote to the Council, Nursing Home, Hospital Trust and Ambulance Trust to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance.
11. I took advice from two of PHSO’s Clinical Advisers – an Advanced Clinical Practitioner and Registered Nurse (our Nursing Adviser) and a Consultant Physician and Geriatrician (our Medical Adviser). Both advisers confirmed they did not have any conflicts of interests and we gave both access to relevant evidence.
12. I gave Mr B and the organisations an opportunity to comment on my draft decision. I considered all of the comments I received in response.

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What I found

13. Mrs B had several long‑term health conditions including type two respiratory failure. In November 2019 she went into hospital and medics diagnosed she was suffering from sleep apnoea. They advised her to wear a CPAP mask for four hours a night. Mrs B left hospital and moved into the Nursing Home in late December 2019. The Council began funding the placement in February 2020 and Mrs B received a Funded Nursing Care contribution.
14. In late February 2020 the Nursing Home completed a Health and Wellbeing care plan for Mrs B. It noted the medical advice for her to use a CPAP mask overnight but that she was refusing to wear it for any longer than one hour.
15. Mrs B’s family spoke to her via a video call on 26 March 2020 and found her to be fine. Records from the Nursing Home from this time also noted staff did not have any concerns about her health.
16. On the following morning staff noted that Mrs B had a dry cough and was wheezy. The staff member took Mrs B’s observations and gave her some paracetamol. They also offered Mrs B the CPAP mask but Mrs B would not wear it.
17. In the middle of the morning a member of staff noted Mrs B sounded chesty and took her observations. They noted Mrs B seemed cheerful but asked for a GP visit due to her risk factors. The GP, in turn, asked the Hospital Trust’s Rapid Intervention Team (RIT Team) to visit Mrs B.
18. An Advanced Nurse Practitioner (ANP) from the RIT Team visited Mrs B in the early afternoon. They took Mrs B’s observation and examined her. The ANP noted Mrs B did not have a cough and did not appear short of breath. They concluded that Mrs B may have a viral infection or may have Covid. The ANP advised Nursing Home staff to give Mrs B paracetamol four times a day and to monitor her observations. They also encouraged Mrs B to use the CPAP mask for longer than 30 minutes. The ANP told Nursing Home staff they should contact the RIT Team again if Mrs B got worse and gave them the number for the Coronavirus Management Centre.
19. On the next day (28 March 2020) Nursing Home staff felt Mrs B had deteriorated and asked someone from the RIT Team to review her again. An ANP from the RIT Team visited Mrs B around lunchtime. They took Mrs B’s observations, examined her and noted she had laboured breathing but did not have a cough. They noted it appeared Mrs B may have Covid. The ANP considered whether there would be any benefit to giving Mrs B oxygen and did a trial. However, based on the results they said there would be no benefit to prescribing oxygen for Mrs B. The ANP prescribed a course of oral antibiotics and encouraged Mrs B to use the CPAP mask for longer.
20. The ANP also noted Mrs B had a Do Not Attempt Resuscitation (DNAR) order in place. They advised staff to prepare for end of life care and prescribed anticipatory medications (medications that staff could use to keep Mrs B comfortable as she reached the end of her life). One of the medications was for midazolam (as an injection), to help treat agitation and breathlessness. The ANP said someone from the RIT Team would visit again in two days’ time unless someone contacted them sooner.
21. Mrs B’s family asked whether she could have a test to check whether Mrs B had Covid. The RIT Team advised that testing was not available. Mr A noted concerns about a recent decision – advised to families via a recent text message from the Nursing Home – to treat residents in the Nursing Home rather than to admit them to hospital.
22. On 29 March 2020 Mrs B’s family attempted to contact the Nursing Home but were unable to get through. They then called the RIT Team and said the family felt Mrs B should be in hospital due to previous pneumonias she had suffered. An ANP advised they had prescribed an oral antibiotic which could be used for the treatment of pneumonia, but also noted Mrs B was showing signs of having Covid. Mrs B’s asked for a Covid-19 test for Mrs B but the ANP advised there was no community testing available.
23. Mrs B’s family said they felt Mrs B had deteriorated further since the previous day. The ANP agreed to call the Nursing Home for an update. They did so and the nurse on duty advised the ANP of some of Mrs B’s observations and that she appeared more drowsy. The ANP asked the Nursing Home to call an ambulance, which it did. The Nursing Home also called Mrs B’s family and asked someone to visit as Mrs B was not well.
24. An ambulance arrived at the Nursing Home in the afternoon. The crew called the RIT Team and noted its plan to treat Mrs B in the community and that the Nursing Home agreed with this plan. It also noted there was a plan for a multi-disciplinary meeting the next day to discuss Mrs B’s care. The ambulance crew took Mrs B’s observations, gave her some oxygen and took her observations again twice over the next hour. The crew told the Nursing Home to encourage Mrs B to use the CPAP mask and left the scene, noting the Nursing Home should call back if Mrs B’s condition deteriorated.
25. On 30 March 2020 night staff noted Mrs B had worn the CPAP mask until 6am. They took her observations and recorded that her oxygen levels were still low.
26. A consultant from the RIT Team visited Mrs B in the afternoon. They took her observations, examined her and noted her history. The consultant noted that, despite the antibiotics Mrs B had taken, her temperature had risen and she looked more poorly. The consultant concluded that Mrs B may have pneumonia or possibly Covid, but was likely approaching the end of her life. The consultant spoke to Mrs B’s family. They said it would not be appropriate to give Mrs B oxygen because it would be detrimental to her on account of the type two respiratory failure she had. Further, the consultant said that admitting Mrs B to hospital would not change the outcome. The consultant changed the type of antibiotic.
27. Mrs B’s family remained with her. In the evening they spoke to Nursing Home staff and insisted they call an ambulance. A nurse did so and an ambulance arrived shortly after. The crew noted recent events and called the RIT Team. An ANP advised the ambulance crew that it would be better for Mrs B to remain in the Nursing Home as there was no further treatment that a hospital could offer. The ANP said the Nursing Home should use the anticipatory medication to keep Mrs B comfortable. The ambulance crew passed this message to the Nursing Home and encouraged them to use the CPAP mask.
28. In the early hours of 31 March 2020 a nurse from the Nursing Home staff spoke to Mrs B’s family about administering an injection to her. Mrs A said the nurse asked several times. The nurse administered an injection of midazolam.
29. Mrs B died in the early morning of 1 April 2020 with her family present. A nurse completed an Expected Death Verification form. On the following day the consultant from the RIT Team completed the Medical Certificate of Cause of Death. It records the primary cause of death as “Pneumonia – Possible Covid”.
30. Mr A complained to the Trust in early April 2020 about its role in Mrs B’s care. Mr A also wrote to the Council about a range of concerns, many of which it forwarded to the Nursing Home. Mr A wrote to the Nursing Home directly in late May 2020.

Analysis

Care between 27 March and 1 April

31. The evidence does not suggest there was any delay in the Nursing Home seeking help when Mrs B’s health deteriorated in late March 2020. The Nursing Home records, along with Mr A’s recollections, suggest that before 27 March 2020 there were no clear outward signs of new ill health which the Nursing Home failed to react to. Also, when the RIT Team received the referral it reacted quickly and visited Mrs B the same day.
32. In Mrs B’s case the RIT Team reviewed her in person and detailed her vital observations the results of a physical examination. The clinical assessment the ANP completed on 27 March 2020 was suitably structured and detailed. As such, there is evidence to show the Hospital Trust took proportionate and appropriate steps before it reached a provisional diagnosis. Further, the plan it made in response to that diagnosis was understandable and in line with the ANP’s findings.
33. The ANP noted Mrs B may have Covid but there was no opportunity to have a test. On 12 March, as the number of cases in the community rose, testing and contact tracing of members of the public in England ended. Instead, a case in the community was defined based on an individual’s symptoms and their likely exposure to someone with the virus, rather than on a positive test result. As such, the ANP’s diagnosis, based on Mrs B’s presenting symptoms, was appropriate.
34. In addition, even if the community testing situation had been different in late March 2020, and Mrs B received a positive Covid test, the treatment plan would not have been any different.
35. The evidence from the Nursing Home records shows staff continued to monitor Mrs B and reacted to concerns that her health was getting worse by asking the RIT Team to come back. This was appropriate and allowed for a further, more specialist review of Mrs B’s needs.
36. On 28 March 2020 the ANP again completed a suitable and appropriate clinical assessment before making a diagnosis. Further, the diagnosis they reached was in line with Mrs B’s presenting symptoms. The ANP prescribed a suitable antibiotic which is a recognised treatment for chest infections. In addition, the decision to prescribe midazolam as an anticipatory medication was in keeping with guidance from the National Institute for Health and Care Excellence (NICE): Care of dying adults in the last days of life (NG31). The decision to prescribe 2.5mg an hour was within the range of acceptable practice for this type of medication for this purpose. The RIT Team’s decision to prepare for end of life care, and to focus on keeping Mrs B as comfortable as possible was appropriate.
37. I have not seen evidence to suggest professionals denied Mrs B access to hospital because of a ‘blanket policy’ of not transferring any Nursing Home patient to hospital. The evidence shows that, on the RIT Team’s advice, the Nursing Home obtained an ambulance for Mrs B. However, professionals determined that a hospital would not be able to offer Mrs B any additional treatment than she was receiving in the Nursing Home. In particular, the RIT Team’s decision that it would not be appropriate to offer Mrs B oxygen was reasonable in relation to her underlying medical condition.
38. In relation to this, it is important to view these events in the context of the emerging Covid pandemic. On 17 March 2020 the NHS Chief Executive and NHS Chief Operating Officer sent a letter to the Chief Executives of all NHS Trusts along with CCGs, GPs and Community Health Services: Important and Urgent – Next Steps on NHS Response to Covid-19. This letter warned NHS staff to prepare for a rapidly increasing pandemic and, because of this, to “Free-up the maximum possible inpatient and critical care capacity”. This included advice to urgently discharge all hospital inpatients who were medically fit to leave.
39. In addition, on 27 March 2020 NICE issued guidance NG159 about who hospitals should be admit for critical care: COVID-19 rapid guideline: critical care in adults. This guided staff to assess the frailty of patients by using a Clinical Frailty Score (CFS) for all patients over 65. (CFS is a widely accepted tool for simply and quickly assessing an older person’s frailty, using a score of 1 (fit and healthy) to 9 (someone close to death). The score relates to a person’s dependency on help. It acknowledges that people who are more frail are less likely to recover from illness.) The NICE guidance guided that clinicians should consider people with a CFS score of 4 or below for intensive care/critical care. In terms of the practical application of this in the NHS, the guidance effectively advised NHS professionals that people with a CFS score of 5 or above should generally not be sent to an intensive care/critical care bed because of the overwhelming pressure on these beds and the need to prioritise who was most likely to benefit from them.
40. Based on the evidence to hand, it is probable Mrs B would have had a CFS score of 7. As such, it would have been reasonable for the RIT Team to have anticipated that, given Mrs B’s frailty, she would not have been able to access an intensive care bed in hospital even if an ambulance had taken her there.
41. There is evidence to show the paramedics undertook a comprehensive review of Mrs B’s presentation and appropriately sought advice from the RIT Team. It acted on the advice given to it and provided advice in the event that Mrs B’s condition worsened.
42. When a consultant from the RIT Team reviewed Mrs B on 30 March 2020 they did so in line with the General Medical Council’s guidance on Good Medical Practice. The consultant included a clear acknowledgement of Mrs B’s past medical history and completed a suitable examination. Based on Mrs B’s past medical history and the findings of the consultant’s examination, the consultant reached a reasonable differential diagnosis of what was likely to be causing Mrs B’s ill health.
43. The outcome of the consultant’s assessment was that Mrs B appeared to be near the end of her life. From the information available, this conclusion appears to have been clinically appropriate. In the context of the situation and guidance at the time, and taking account of Mrs B’s past medical history and examination, the consultant’s plan to keep Mrs B in the Nursing Home and focus on keeping her as comfortable as possible was reasonable and appropriate.
44. It was appropriate for the Nursing Home to administer an injection of midazolam in the early morning of 31 March 2020. Staff gave it for the reason it had been prescribed and gave the correct, prescribed dosage.
45. Overall, the evidence shows the Nursing Home, Hospital Trust and Ambulance Trust responded to the deterioration in Mrs B’s health appropriately. Professionals completed suitably detailed examinations of Mrs B, took account of her history and acted in line with the guidance in place at the time. As such, I have not found evidence of fault by any of the organisations. Further, I am satisfied the organisations’ responses to Mr A’s complaints were a fair and proper reflection of events.

Nursing Home’s response to the family’s request for records

46. Mr A first asked for a copy of Mrs B’s records in an email in late May 2020. The Nursing Home initially replied to say it did not hold Mrs B’s medical records and suggested Mr A contact the GP. Mr A replied in late June 2020. He clarified that “We are not asking for the complete medical records, we are asking for any records you have on [Mrs B] e.g. records you have to keep in the period concerned”. Mr A reiterated his request for the records in another email several days later.
47. The Nursing Home responded in the second half of July 2020. It again suggested Mr A should discuss his request with the GP, or the RIT Team via the Patient Advice and Liaison Service or a solicitor. The Nursing Home again said it did not hold medical records.
48. Mr A repeated his request for copies of Mrs B’s records in October 2020. The Nursing Home replied the same day and asked for a copy of the relevant Power of Attorney document and said it would forward this to its legal team. Mr A asked for clarification of whether this meant the Nursing Home could provide copies of records, and queried why the Nursing Home had not asked for this document previously. The Nursing Home replied and said “Power of attorney is required for the release of any records”.
49. The Nursing Home did not handle Mr A’s request for copies of Mrs B’s records transparently. It took a considerable amount of time until it first requested a copy of any documents from Mr A to aid the request. Further, it did not provide any information about its own policies on data protection or offer any signposting to relevant information elsewhere. This was fault on the part of the Nursing Home and caused Mr A avoidable stress, time and trouble. I have made a recommendation to address this below.
50. The UK General Data Protection Principle (GDPR) does not apply to the records of a deceased person. People can request access to a deceased person’s records through the Freedom of Information Act 2000 (the FOIA). There are no specific exemptions under FOIA for information about deceased people. However, certain exemptions apply, including about access to confidential information. Both the Information Commissioners Office (the ICO) and the British Medical Association (the BMA) have noted that the information contained in medical records will generally be confidential, and the duty to keep the information confidential continues after death. Similarly, people can request heath records via the Access to Heath Records Act 1990. However, people will only be able to access to a deceased person’s health records if they are either:

• a personal representative (the executor or administrator of the deceased person's estate) or,
• someone who has a claim resulting from the death (this could be a relative or another person).

51. Only information directly relevant to a claim will be disclosed.
52. Because of these factors, it is not for the Ombudsmen to determine whether the Nursing Home should release Mrs B’s records to Mr A. This is a decision for the Nursing Home to make, following the appropriate legislation and guidance. Once the Nursing Home has responded it would then be open to Mr A to go to the ICO should he feel the Nursing Home did not handle his request appropriately.

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Agreed actions

53. Within one month of the final decision the Nursing Home will write to Mr A to acknowledge it did not handle his requests for copies of Mrs B’s records transparently. It will also apologise for the avoidable stress, time and trouble this caused Mr A.
54. Within one month of the final decision the Nursing Home will write to Mr A to fully explain its policy and procedures in relation to people who make requests for copies of deceased residents’ records. It will set out what it needs from Mr A, and explain the timescales and next steps. The Nursing Home should handle the response from Mr A in line with the relevant legislation and guidance and its own policies.

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Decision

55. I have completed this investigation on the basis there was no fault by any of the organisations in regard to the care services provided to Mrs B.
56. However, there was fault in the way the Nursing Home responded to Mr A’s request for copies of Mrs B’s records. I have made recommendations to address the impact of this fault.

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Parts of the complaint that I did not investigate

57. I did not investigate issue (a) as the complaint to the Ombudsmen was late. A complaint is ‘late’ when a person makes their complaint more than 12 months after they knew of their concerns. The Ombudsmen have the discretion to set this time limit aside, but only if there are persuasive reasons to do so. In this instance, having considered Mr A’s views, I did not find a clear reason to exercise discretion and look at this issue.
58. I did not investigate issue (b) as I could not see that Mr A had ever made this complaint to the relevant hospital departments which made the appointments. Further, it is unlikely an investigation would lead to a finding of a significant injustice linked to this issue. In addition, given the time that has passed it seems unlikely an investigation would be able to produce a worthwhile outcome, in terms of putting things right.
59. I did not investigate issue (c) as I could not see that the Ombudsmen would be able to usefully investigate this issue. An Ombudsmen investigation would not be able to independently and fairly establish whether there had been issues with the heating in Mrs B’s room at specific points in the past. And, even if it were able to, there is no clear way of fairly and independently establishing what the individual impact would have been on Mrs B in the short‑ or long term.
60. I did not investigate issue (d) as, to my knowledge, there was no suggestion that Mrs B missed any hospital appointments. As such, while I appreciate this was very frustrating for the family, an investigation would not be able to establish an impact which would constitute a serious injustice linked to this issue.
61. I did not investigate issue (e) as I did not believe an investigation would have a realistic prospect of making a meaningful finding. Mr A has noted he has two messages from a dentist in relation to this issue. An investigation could look at these and would also be able to request the Nursing Home’s medication administration records. However, even with this information it is likely to be difficult to reach an evidence-based view on what happened, and the complaint is likely to come down to one person’s view against another’s.
62. I did not investigate issue (f) because, as with the issue about heating, I do not believe there is any way for the Ombudsmen to usefully and fairly investigate this issue. I cannot see a way for the Ombudsmen to establish if the specific machine Mrs B had in March 2020 was working at any given point.
63. I did not investigate issue (g) as I do not consider this issue, on its own, is likely to link to a specific, individual injustice to Mrs B. This is because professionals made the decisions to care for Mrs B in the Nursing Home based on evaluations of her individual circumstances and not based on a blanket policy. In particular, it is notable that the RIT Team advised the Nursing Home to call an ambulance for Mrs B and the Nursing Home did so. The Trust supplied a rationale for why it did not feel it would have been beneficial to have admitted to Mrs B to hospital. Again, this rested on the specifics of her case and not on a blanket policy.
64. I did not investigate issue (j) as an investigation would not be able to provide any greater certainty on whether Mrs B had Covid-19. Even if we were to accept that, on balance, she did have it, an investigation would not be able to establish and how and when she contracted it. Nor would it be able to say whether the Nursing Home could have reasonably prevented this by using practices recommended at the time. Overall, the Ombudsmen are unlikely to be able to make an evidence-based decision about an avoidable personal injustice related to this issue.
65. I did not investigate issue (k) as a specific issue for the same reasons as issue (i). Further, the investigation I undertook was able to give a view on whether the professionals involved in Mrs B’s case made reasonable diagnoses based on good practice and the guidance in place at the time.
66. I did not investigate issue (l) as I did not consider an investigation would have a realistic prospect of establishing a specific personal injustice. Further, I did not consider an investigation would be able to reach an outcome that would help to resolve the complaint. Professionals completed a Medical Certificate of Cause of Death (MCCD) following Mrs B’s death. This included the conclusion that Mrs B probably had Covid-19. An investigation by the Ombudsmen would not be able to provide any greater clarity about whether Mrs B had Covid-19 or not. Further, the Ombudsmen could not amend the MCCD.
67. I did not investigate issue (m) as there was not a realistic prospect of linking any failings to a significant personal injustice. To my knowledge the Coroner did not have any jurisdiction to act as the MCCD reported that Mrs B died of natural causes. Further, Mr A was able to liaise with the coroners’ offices and ask questions of them and obtain information.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman