The Ombudsman's final decision:
Summary: Mrs X complained about the coroner’s office’s delay carrying out her late partner’s post mortem. The coroner’s office acted without breaching the general standards set by the Ministry of Justice and therefore without fault.
- Mrs X complains the coroner’s office took too long to allocate an officer to investigate the death of her partner. This caused a 21 day delay releasing him back to his family and meant some family members could not view him before his funeral.
- Mrs X says the coroner’s office did not communicate directly with her funeral directors which caused her considerable distress at a difficult time.
- She says these problems caused a seven week delay before she could hold a funeral service. Mrs X wants the Council to explain how it has learnt from her complaint to improve service for others.
The Ombudsman’s role and powers
- We investigate complaints about councils and certain other bodies. Where a coroner’s office is providing services on behalf of a council, we can investigate certain complaints about the actions of that office as if they were those of the Council. (Local Government Act 1974, section 25(7), 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
- I wrote to Mrs X about her complaint, checking my understanding of it.
- I wrote to the Council asking questions and considered its reply.
- I considered the Ministry of Justice guide to coroner’s services and, in particular, the general standards set out in that guide.
- I gave the Council and Mrs X the opportunity to comment on my draft decision.
What I found
- A coroner is an independent judicial office holder appointed by a council. The coroner investigates deaths reported to it in certain circumstances. Coroners direct the work of coroner’s offices.
- The Coroners and Justices Act 2009 requires councils to secure provision of coroner’s offices.
The Local Government and Social Care Ombudsman (LGSCO) role in coroner’s complaints
- The Ministry of Justice guide to coroner’s services is statutory guidance issued by the Lord Chancellor under section 42 of the Coroners and Justice Act.
- The guidance includes general standards that people can expect during a coroner’s investigation. The only standard that relates to timescales is that the coroner’s office will “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 delays”.
- The guidance gives advice on how someone can complain about a coroner. Paragraph 11.5 guidance states “if you need to complain about the way a coroner or his or her staff handled an investigation (for example if you feel the standards in the booklet are not being met) you should first write to the coroner, and copy your letter to the local authority which funds the service.
You may also complain direct to the local authority (council). If you are still dissatisfied after its response you may complain to the Local Government Ombudsman”.
- The statutory guidance distinguishes between complaints about service standards and those about a coroner’s personal conduct. Complaints about a coroner’s personal conduct are dealt with by the Judicial Conduct Investigations Office (JCIO). That office can investigate matters such as the coroner’s personal behaviour, unreasonable delays in holding an inquest, or replying to correspondence.
- The LGSCO can investigate complaints that a coroner’s service has breached the general standards set out in the Ministry of Justice’s guidance.
- This council uses the Ministry of Justice standards to guide the actions of its coroner’s office.
- Mrs X’s partner, Mr X died in February 2018. Because this was a sudden death the coroner decided to carry out a post mortem. A pathologist carried out the post mortem just over three weeks later in March. The coroner made her decision, that day, to release Mr X to the funeral director.
- The coroner’s office contacted Mrs X’s funeral directors the same day of the post mortem. It explained Mr X’s body had now been released for burial.
- Mrs X complained to the Council in May 2018 about the time it had taken for the post mortem to be completed. She said this had caused the family a great deal of stress and upset. She said it meant the family had not all been able to view Mr X before burial. She asked the Council to explain why it had taken this long.
- The Council replied to apologise for what happened. It said the level of service had not been acceptable. It had been caused by the pressure on the service at that time. It explained it had, since then, reviewed the service and appointed two officers to fill vacancies. It referred Mrs X to the Ombudsman.
- Mrs X complained to us. She said the Council had not explained what it was doing to prevent this happening again. She wanted to avoid other families being similarly distressed. She said the coroner’s office should have contacted the funeral directors directly to keep them informed about what was happening.
- In its reply to my enquiries, the Council said it had learnt from pressures on services caused by deaths during last winter. It had recruited new staff, set up a new computer system and was working with the NHS and other organisations to improve its service.
- The Ombudsman can only consider whether coroner’s offices have breached the general standards, as set out by the Ministry of Justice.
- The only standard relating to timescales covers cases that go on for longer than three months. The coroner’s office’s involvement in this case lasted for two months.
- Therefore whilst more regular contact with Mrs X or her funeral directors might have been helpful, the coroner’s office did not break the general standards. We therefore cannot say there was fault in its actions.
- The Council has, nevertheless, apologised for its delays. It has now also explained what it has done to prevent their reoccurrence.
- I have completed my investigation. There was no fault by the Council.
Investigator's decision on behalf of the Ombudsman