The Ombudsman's final decision:
Summary: Mrs X says there has been fault by the Council in how it has provided the administrative services of the Coroner’s Office. The Ombudsman has ended his investigation of this complaint because he has not found evidence of fault by the Council.
- Mrs X complains about the administrative services provided by the Coroner’s Office following the death of her father. She says it has failed to:
- respond to her questions and enquiries;
- provide a copy of the contract between the coroner and the pathologist;
- to provide an explanation of the pathologist’s report;
- explain the retention by the NHS of some of her father’s remains after a post-mortem examination; and
- respond to her complaints.
Mrs X says she has been caused significant distress, anxiety and time and trouble in pursuing her complaints.
- I have investigated Mrs X’s concerns as set out above with the exception of her concerns about the retention of some of her father’s remains following the post-mortem examination. The later part of my statement explains my reasons for not doing so.
The Ombudsman’s role and powers
- The law says we cannot normally investigate a complaint when someone can appeal to a tribunal. However, we may decide to investigate if we consider it would be unreasonable to expect the person to appeal. (Local Government Act 1974, section 26(6)(a), as amended)
- The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
- We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
- If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- As part of my investigation I considered Mrs X’s complaint and information provided by her. I also considered information provided by the Council. I set out my initial thoughts on the complaint in a draft decision statement and I invited Mrs X and the Council to comment.
What I found
- This guide explains the standards that can be expected during a coroner’s investigation. It says the coroner’s office will:
- Explain the role of the coroner and answer your questions about coroner investigations;
- Give you contact details for the office;
- Help you understand the cause of death;
- inform you of your rights and responsibilities;
- take account where possible of your views and expectations including family and community preferences, traditions and religious requirements relating to mourning, post-mortem examinations and funerals;
- provide a welcoming and safe environment and treat you with fairness, respect and sensitivity;
- act with compassion and without judgement about the deceased and the cause of death;
- treat children and young people involved in an investigation in an age- appropriate way;
- make reasonable adjustments, whenever possible, to accommodate your needs if you have disability;
- help you find further support where needed;
- during a long investigation, unless otherwise agreed with you, contact you at least every three months to update you on the progress of the case, and explain reasons for any further delays;
- explain, where relevant, why the coroner intends to take no further action in a particular case.
- The guide also provides information about how to challenge a coroner’s decision or complain about the standard of service received. It says the following:
- If a person wishes to challenge the decision of the coroner then they will need to make an application to the High Court for a judicial review of the coroner’s decision;
- Complaints about the personal conduct of the coroner should first be made to the coroner. If the coroner was unable to deal with the matter then the matter should be referred to the Judicial Conduct Investigations Office for consideration.
- Complaints about the pathologist who conducted the post-mortem should be referred to the coroner. If the complaint is serious the complaint should also be made to the General Medical Council
- If the complaint is about the way the coroner or their staff handled an investigation you should complain to the coroner or the relevant local authority. If you remain dissatisfied then you can complain to the Local Government and Social Care Ombudsman.
Nottingham City Council Serial or Unreasonably Persistent Complainant/Behaviour Policy
- This policy explains what behaviour the Council considers amounts to unreasonable behaviour while it investigates a complaint made to it. The policy says that when a person’s behaviour has been deemed unreasonable it will write to the person to explain the policy has been implemented and provide details of how the Council will communicate with the person in future.
- The policy also says the Council will continue to investigate the complaint made by that person. The restriction on contact will only last for the duration of the complaint. However, if the person continues to act in an unreasonable way each time they contact the Council, then a review may be necessary.
- Mrs X’s father died within 24 hours of being admitted to hospital in November 2017. Mrs X’s father’s next of kin was Mrs X’s mother.
- The coroner ordered a post-mortem into the death.
- The post-mortem found Mrs X’s father had died from natural causes. The pathologist who carried out the post-mortem retained some tissue samples from her father while the case remained open with the coroner.
- Mrs X disputed the findings of the coroner and the post-mortem. She says the doctors’ death certificate says her father died from causes he did not die from and the doctors had never seen her father. For these reasons Mrs X asked that an inquest be held.
- The coroner refused her request.
- In December Mrs X made a complaint about the service she had received from the Coroner’s Office. She said the Office had:
- taken too long to answer the phone;
- put her on hold for 45 minutes;
- not helped her obtain an interim death certificate;
- told her it would not communicate with her; and
- upset her as result of the manner and attitude of its staff.
- The Council’s reply to her complaint said:
- the office is very busy on Mondays owing to matters that arise during the weekend and this is why it did not answer the phone sooner;
- it had problems with its phone systems on the day she was placed on hold and this was why she had been on hold for so long;
- an interim death certificate had been sent to her on 15 December; and
- the referral form from the Hospital and Bereavement Team stated that Mrs X’s mother wanted Mrs X’s sister to be the point of contact for the family. Nevertheless the Practice Manager for the coroners’ support had told her they would act as point of contact as Mrs X was not in contact with her sister.
- The Council also told Mrs X that on the instruction of the Senior Coroner it would not be releasing to her a copy of the ‘tissue wishes’ form that would have dealt with the samples retained by the pathologist until the coroner ended his investigation.
- Mrs X was unhappy with the Council’s responses and contacted the Council many times to express this. However she did not ask the Council to escalate her complaint but instead asked officers not to contact her as she felt their behaviour constituted harassment.
- In turn, the Council wrote to her explaining that it found her behaviour to be unreasonable and that it would be limiting her contact with the Council. She was given a single point of contact at the Council.
- In January 2018 the Coroner’s Office told Mrs X that the coroner had concluded her consideration of her father’s death and closed the case. It provided Mrs X with a copy of the post-mortem report.
- In May Mrs X contacted the Council again resulting in her making another complaint. Mrs X said that staff dealing with her had been rude and put the phone down on her without good reason. She was also unhappy the Council advised her it was not part of the pathologist’s remit to meet with people to go through the post-mortem report.
- The Council replied explaining that it had listened to a recording of the conversation between its officer and Mrs X but did not consider the officer had been rude. It advised that it found her behaviour to be unreasonable and that it would be restricting her contact to a single person at the Council. The Council told Mrs X that if she was unhappy with its actions then she could contact the Ombudsman. Mrs X did so.
- In June Mrs X made a Freedom of Information request to the Council asking for details of the contract between the coroner and the pathologist. The Council provided a response in July which included a redacted copy of the contract.
The Coroner’s Office failed to reply to her enquiries
- I do not agree with Mrs X’s view that the Coroner’s Office did not reply to her enquiries. The information I have seen demonstrates it responded to all of Mrs X’s substantive enquiries regarding the coroner’s investigation of her father’s death. Mrs X was provided with a copy of the interim death certificate for her father as she requested. She was also notified about the outcome of the coroner’s consideration of her father’s death and provided with a copy of the post-mortem report.
- Furthermore, the Coroner’s Office was advised by Mrs X’s mother, and her father’s next of kin, that Mrs X’s sister was to be the point of contact for the family. Accordingly, the Council dealt with her sister regarding the case. I note that it was aware Mrs X was not in contact with her sister and nominated an officer to act as a point of contact for her.
The Council failed to provide a copy of the contract between the coroner and pathologist or an explanation pathologist’s report
- The Council acted upon Mrs X’s request for this information and a redacted copy of the contract was provided to her. I do not find fault by the Council.
- I am aware that Mrs X requested a meeting with the pathologist to discuss the report. The request was declined because explaining the report is not part of the pathologist’s remit. If Mrs X disagrees with this view then she should complain about the pathologist using the route set out in the Ministry of Justice’s Guide to Coroner Services.
The Council failed to respond to Mrs X’s complaints
- I do not agree with Mrs X’s view that the Council did not reply to her complaints. I have been provided with a copy of the Council’s reply to her complaint of December 2017. I am therefore satisfied it responded. I have also been provided with copies of Mrs X’s emails in response. While these express dissatisfaction with the Council and its reply, they do not request that her complaint is escalated. Moreover, the emails sent by Mrs X requested that officers do not contact her further.
- Mrs X complained again in May 2018. Again, I have been provided with a copy of the Council’s response to the complaint. For this reason, I am satisfied it responded. The Council advised Mrs X that if she was still unhappy she could approach the Ombudsman, which she has done.
- I note that on both occasions the Council invoked its Unreasonably Persistent Complainants Policy. This was communicated to Mrs X on both occasions and she was told that communication would be restricted to a single point of contact. She was advised that communication to other officers would not be replied to and that only new issues would receive any substantive response. I am satisfied the Council followed its policy when deeming Mrs X’s behaviour to be unreasonable. Therefore I do not find it at fault for not replying to Mrs X’s communications which fell outside of the scope of the restricted contact the Council advised her was in place.
- I have ended my consideration of this complaint as I have not found evidence of fault by the Council in this matter.
Parts of the complaint that I did not investigate
- The Senior Coroner decided not to share this information with Mrs X. The actions of the Senior Coroner are outside the jurisdiction of the Ombudsman and therefore cannot be investigated. Concerns about the conduct of the Senior Coroner should be made to the Judicial Conduct Investigations Office.
Investigator’s final decision on behalf of the Ombudsman
Investigator's decision on behalf of the Ombudsman