Summary: Ms X complained about the Coroner’s failure to meet service standards set by the Ministry of Justice. We cannot investigate Ms X’s complaint. This is because we cannot investigate the actions of the Coroner’s Office before April 2019 as they were managed and directed at that time by the Metropolitan Police.

The complaint

1. Ms X complained the Coroner and the Coroner’s Office failed to meet service standards following her brother-in-law’s death.

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The Ombudsman’s role and powers

2. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
3. 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)
4. However, Coroner’s Officers may also be employed and paid for by the local police service. We cannot investigate the actions of the police service. Therefore, in those circumstances we cannot investigate the actions of the Coroner’s Officers. (Local Government Act 1974, sections 25 and 34A, as amended)

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How I considered this complaint

5. I spoke to Ms X about her complaint.
6. I considered the Ministry of Justice Guide to Coroner Services, the Coroners (Investigations) Regulations 2013 and the Coroners and Justices Act 2009
7. I considered guidance on the Judicial Conduct Investigations Office and Judicial Appointments and Conduct Ombudsman’s websites.
8. I spoke to the Coroner's Office and considered its reply to my enquiries.
9. I wrote to the Council and considered its response.
10. I wrote to Mr X, the Coroner and the Council with my draft decision and considered their comments before I made my final decision.

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What I found

Key law and guidance

The Coroner, Coroner’s Office and Council roles

11. A coroner is an independent judicial office holder appointed by a council. The coroner investigates deaths reported to in certain circumstances. Coroners direct the work of coroner’s officers.
12. 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.
13. The West London Coroner District covers six London boroughs, including Hammersmith and Fulham which is the lead authority.
14. Before April 2019, and therefore during the period covered by this complaint, the Coroner’s main administrative staff were employed directly by the Metropolitan Police. Neither the London Borough of Hammersmith and Fulham, nor the other councils, had management control over them.
15. In April 2019, responsibility for funding and employing the Coroner’s Office staff transferred from the Metropolitan Police to the London Borough of Hammersmith and Fulham and the other West London Boroughs in the area.

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

16. 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. This gives advice on how someone can complain about a coroner. Paragraph 11.5 of the 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”.

17. 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.
18. Once a person’s complaint to the JCIO is concluded, they can complain about that office’s investigation to the Judicial Appointments and Conduct Ombudsman. That Ombudsman can consider whether compensation should be paid if it believes a complainant has suffered because of maladministration.
19. The LGSCO can investigate complaints that a coroner’s service has breached general standards set out in the Ministry of Justice’s guidance. But it can only do that where the coroner’s service is provided by a body within our jurisdiction. Where the service is provided by the police service we have no power to investigate its actions. The statutory guidance says nothing about a situation where the coroner’s office is provided and managed by the local police service.

Background

20. The six London Boroughs of West London pay for the Coroners that operate in their area. Up until April 2019, and so during the period covered by this investigation, the main Coroner’s Officers were paid for and directly employed by the Metropolitan Police. A number of support service staff, who dealt with back office duties such as invoices and payroll, were employed and paid for by the six Councils.
21. Ms X complained to the Coroner and the Council about how the Coroner’s Office handled a case relating to her brother-in-law, Mr Z. She said the Coroner and the Coroner’s Office failed to:
• send her a copy of the autopsy report;
• advise her how to legally challenge the report;
• properly store some of Mr Z’s organs after the autopsy; and
• tell her it had closed her case.
22. Ms X contacted the Ombudsman about her complaint. She said the Council had told her that it did not have jurisdiction over the Coroner or the Coroner’s Office and so could not deal with her complaint. She said the Coroner had not provided her with a proper response.

My findings

23. Ms X’s complaint to the Ombudsman concerns the actions of the Coroner, and of Coroner’s Officers in respect of the way they handled the death of Mr Z.
24. The Ombudsman cannot investigate the conduct of the Coroner.
25. The Ombudsman can investigate certain administrative actions of Coroner’s Officers but only if that service is paid for and employed by the Council.
26. The Coroner’s Officers in the West London Coroner’s District are employed and paid for by the Metropolitan Police. We therefore cannot investigate the matters about which Ms X complains.
27. I have stopped my investigation. This is because the actions Ms X complained about are not administrative functions of the Council.

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Final decision

28. I have stopped my investigation. This is because the actions Ms X complained about are not administrative functions of the Council.

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Investigator's decision on behalf of the Ombudsman