Summary: There is no evidence of fault in how the coroner’s office stored the body the complainant’s late husband.

The complaint

1. The complainant, whom I shall refer to as Mrs C, complains on behalf of her sister, whom I shall refer to as Mrs Z, about how the Coroner’s office handled the storage of the body of Mrs Z’s late husband, whom I shall refer to as Mr Z.
2. Mrs C says the coroners failed to place Mr Z’s body into deep freeze, which led to the body decomposing, meaning Mrs Z was unable to view Mr Z’s body before his funeral.

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The Ombudsman’s role and powers

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. As part of the investigation, I have:
• considered the complaint received from Mrs C; and
• reviewed and considered information received from the Council; and
• considered any relevant planning law and guidance; and
• communicated with Mrs C about her complaint.
6. I also sent a draft version of this decision to both parties and invited their comments.

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What I found

Key law and guidance

The Coroner, Coroner’s office and Council roles

7. A coroner is an independent judicial office holder appointed by a council. The coroner investigates deaths reported in certain circumstances. Coroners direct the work of coroner’s officers.
8. Section 24 of the Coroners and Justices Act 2009 requires councils to secure provision of coroner’s offices. However, in some parts of the country, the local police service employs, manages and directs the work of the coroner’s officers and administrative staff.
9. A council’s statutory and administrative functions therefore include provision of coroner’s services. However, the coroner’s officers’ work is always carried out under the authority of the coroner who works independently from both the council and police force.

The Local Government and Social Care Ombudsman (LGSCO) role in coroner’s complaints

10. The Ministry of Justice guide to coroner’s services is statutory guidance issued by the Lord Chancellor under section 24 of the Coroners and Justice Act.
11. 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 Human Tissues Authority

12. Mortuaries are licenced by the Human Tissues Authority (HTA), who have issued guidance on the storage of bodies. It says ‘refrigeration of bodies should be at a temperature of approximately 4 degrees Celsius’.
13. Further guidance from the HTA says ‘bodies should be moved into frozen storage after 30 days in refrigerated storage, if there is no indication they are soon to be released or further examined, depending upon the condition of the body’

What Happened

14. Mr Z died on 16 December, and his body was transferred from the hospital to the Council’s public mortuary on 19 December, where he was placed into refrigerated storage.
15. The mortuary has a policy that bodies are checked upon receipt and a risk assessment form is completed detailing the condition of the body and recording if there are any cuts, abrasions, damage or decay.
16. Records show that checks of Mr Z’s body showed bruising to his abdomen and abrasions to his chest. It did not record any signs of decay.
17. On 22 December, Mr Z’s body was transferred to another hospital for a post mortem to be carried out. On 28 December, after the post mortem was completed, Mr Z’s body was transferred back to the mortuary.
18. Records show checks of Mr Z’s body were again carried out, which showed bruising to the abdomen but did not record any sign of decay. Mr Z’s body was placed back into refrigerated storage.
19. The Coroner authorised the release of Mr Z’s body, and the release note was passed to the family’s funeral directors. A burial order was signed on 10 January, when Mr Z’s body became available for collection by the funeral directors.
20. Records show that Mr Z’s body remained in refrigerated storage until 17 January, when the funeral directors collected him.
21. During that time, records show that checks were carried out on the temperature of the refrigeration storage unit and show it was kept at no higher than 4 degrees Celsius.
22. Mrs Z complained to the Coroner. She said that she hoped that Mr Z would have an open casket, in line with her religious beliefs. However, she was advised against this by the funeral directors because decomposition meant that Mr Z’s body was in a poor condition.
23. In its response, the Coroner said that bodies will deteriorate over time unless placed in deep freeze, but this would not have been appropriate in Mr Z’s case as his body had been made available for release and it was the funeral directors who delayed collection.

Analysis

24. It was clearly very distressing for Mrs Z and her family to learn about the condition of Mr Z’s body. However, in order to uphold this complaint, I would need to see clear evidence of fault in how the Coroners office dealt with the matter.
25. Records show that once the post-mortem was complete, no concerns were identified with decay and the Coroner’s office therefore followed HTA guidelines when it kept Mr Z’s body in refrigerated storage for 20 days, which is within the maximum of 30 days. Records also show that the refrigeration was kept within the HTA’s temperature guidelines during this period.
26. I have found no evidence that the Coroner’s office failed to follow HTA guidelines when storing Mr Z’s body, I am therefore unable to find fault in how the matter was handled.

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Final decision

27. I have concluded my investigation on the basis that there is no evidence of fault in how the coroner’s office dealt with the matter.

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Investigator's decision on behalf of the Ombudsman