Summary: Mr B complains the coroner’s office gave him incorrect information about which registry office to attend to register his mother’s death. The office accepted fault during its complaint procedure. Mr B also complains about the Council’s complaint handling. There was fault in the way the coroner’s service handled the complaint. The service has agreed to take action to remedy the injustice caused by this fault.

The complaint

1. Mr B complains the coroner’s office gave him incorrect information about which registry office to attend to register his mother’s death. Mr B also complains about the Council’s complaint handling.

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The Ombudsman’s role and powers

2. 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 types of complaint about the actions of that office as if they were those of the council. (Local Government Act 1974, section 25(7), as amended)
3. 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)
4. 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)

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How I considered this complaint

5. I considered:
• Mr B’s complaint and the information he provided;
• documents supplied by the Council;
• relevant legislation and guidelines; and
• the Council’s policies and procedures.
6. Mr B and the Council had an opportunity to comment on a draft decision.

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What I found

Legislation and Guidance

Key law and guidance

7. A coroner is an independent judicial office holder appointed by a council. They investigate deaths reported to them, including those where cause of death is unknown. They direct the work of coroners’ officers who can be civilian employees or seconded police officers. Section 24 of the Coroners and Justices Act 2009 requires councils to fund coroner’s offices, although the local police force might employ certain officers who work for the coroner’s service.
8. Regulation 7 allows a coroner to delegate administrative tasks, but not judicial ones, to members of their staff. The Chief Coroner’s guide says this regulation allows coroners to delegate matters to “include such things as contacting bereaved relatives and making inquiries”. It does not include judicial decision-making such as deciding to order a post-mortem. The guidance notes that “in practice, the distinction between judicial and administrative functions can be blurred and open to interpretation”.
9. The Ministry of Justice publishes a guide to coroner’s services which sets out service standards and offers advice on how to complain about a coroner’s office. It says that if someone considers a coroner’s office has not met the service standards set out in the guide, they should first complain to that service. If dissatisfied, the person can then complain to the council and next, if still dissatisfied, to the Ombudsman. The guide distinguishes complaints about standards from complaints about a coroner’s personal conduct or pathologists who conduct post-mortems.

Coroner’s office complaints procedure

10. The coroner’s office has a three stage complaints procedure:
• Stage 1: complaints are acknowledged.
• Stage 2: a clerk or manager will contact the complainant.
• Stage 3: the complaint is investigated.
11. If the complaint is not resolved it will be passed to the senior coroner who will investigate and provide a written response to the complaint.
12. The office aims to address all complaints within two months from the date the complaint is received.

Council’s complaints procedure

13. The Council has a two stage complaints procedure:
• Stage 1: service investigates.
• Stage 2: the feedback and information governance team investigate.
14. At stage 1 the complainant will get a response within 10 working days and at stage 2 within 25 working days.

What happened

15. This chronology includes key events in this case and does not cover everything that happened.
16. In June 2018 Mr B’s mother’s death was reported to the coroner’s service. The coroner completed post-mortem because the cause of death was unknown. The coroner decided the cause of death was natural and the death could be registered.
17. The coroner’s service told Mr B he could register his mother’s death and collect her death certificate from registry office C. When he attended office C, he was told he needed to go to registry office D.
18. Mr B went to office D and staff arranged an appointment for him for the following day so he could collect his mother’s death certificate.
19. In July 2018, Mr B complained the service told him to attend the wrong registry office to collect his mother’s death certificate. The following day the service apologised for the error and confirmed which registry office he needed to attend.
20. Mr B asked the service to take his complaint through its complaint procedure. He said the error had caused him stress, distress, loss of valuable time and expense.
21. Almost two weeks later, Mr B contacted the service chasing a response to his complaint. He told the service he wanted it to contact him by email only.
22. The coroner’s service tried to call Mr B and emailed him to try and arrange a time to speak. Mr B declined and requested communication by email. The service responded to Mr B’s complaint by email. It explained an error was made and corrected, and he had received an apology. The service asked Mr B if there was anything else it could help him with.
23. Mr B told the coroner’s service he expected to be compensated for the stress, distress, loss of time and expense caused by the mistake. He asked the service to tell him about its formal complaint procedure and details of the Ombudsman. The service told Mr B his complaint had been passed to a senior member of staff who would respond within 28 days.
24. The service did not respond within 28 days. In September 2018, Mr B chased it for a response. The service told him he could claim travel fare for his journeys to and from the registry offices. It said it had strengthened its policies and procedures to ensure the same error did not happen again. Mr B said a senior member of staff was yet to respond to his complaint.
25. A senior member of staff from the coroner’s service responded to Mr B’s complain. This response was a month late. The service said an error was made which caused Mr B to attend the wrong registry office. He apologised and explained he had asked the service to:
• clearly explain the complaints process in future;
• check registry office details are correct before paperwork is sent to family members; and
• reimburse Mr B’s travel fare for his journey to registry office C.
26. Mr B made a complaint through the Council’s complaints procedure in October 2018. The Council dealt with his complaint at stage 2 of its complaint procedure. The Council’s complaint response said:
• The coroner was not able to pay compensation.
• The coroner’s office apologised for the error as soon as it was brought to their attention.
• The coroner’s office had asked the court to reimburse Mr B’s travel expenses.
• The enquiries manager would be making checks before paperwork is sent to members of the family to ensure the situation was not repeated.
27. The Council said it could not find fault with how Mr B’s complaint was dealt with and provided details for the Ombudsman.
28. Mr B told the Council its findings were bias and it had not addressed the complaint he had made.

Analysis

29. The coroner’s office accepted it gave Mr B details for the wrong registry office. This caused Mr B injustice because he made an unnecessary journey to registry office C and attended office D to try and resolve the error caused by the coroner’s office. The coroner’s office has apologised and offered to reimburse his travel fare. This is an appropriate remedy for the injustice caused by the fault.
30. It also said it would ask staff to check registry office details are correct before paperwork is sent to family members. This is an appropriate service improvement to stop the error happening again.
31. These responses show the coroner’s officer understood Mr B’s complaint. The office apologised and offered a suitable remedy for its fault. There was no evidence of bias in the way it handled Mr B’s complaint.
32. However, when dealing with Mr B’s complaint, the coroner’s office did not follow its complaint procedure:
• Stage 1: the service responded promptly to Mr B.
• Stage 2: the service tried to contact Mr B by telephone despite him requesting contact by email.
• Stage 3: the service told Mr B he would get a response from a senior member of staff within 28 days. This timeframe is not in the coroner’s office complaints procedure. The service took two months to respond to Mr B at stage 3.
33. Failing to follow its own procedure is fault.
34. Within the complaints process the coroner’s service said it had made service improvements. It said it had told staff to explain the complaints procedure to complainants. However, the main issue was that staff did not follow the procedure and I have made service recommendations to address this.

Agreed action

35. Within one month of the final decision the coroner’s office will honour its offer to reimburse Mr B’s travel fare for the journey to and from registry office C and for one return journey to office D.
36. Within two months of the final decision, the coroner’s office will provide training to its staff on its complaint procedure.

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Final decision

37. I have completed my investigation and uphold Mr B’s complaint. The coroner’s service was at fault for giving Mr B details for the wrong registry office and not following its complaint procedure. These faults caused Mr B injustice and the service has agreed to take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman