Summary: The Council provided an inadequate service to Mrs C and her family following the death of her uncle. This is fault. The Council has provided the family with a written apology and made several service improvements to prevent the faults from reoccurring. The Council’s proposed remedy is appropriate.

The complaint

1. The complainant, Mrs C, complains the Council failed to adequately communicate with her family following the death of her uncle. Mrs C says the Council’s actions caused the family distress.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I considered Mrs C’s complaint and the information she provided.
5. I considered the Council’s response to Mrs C’s complaint.
6. Mrs C and the Council have the opportunity to comment on this draft decision before I make a final decision.

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What I found

7. Mrs C’s uncle, Mr M, died unexpectedly on 10 March 2018. Mr M’s body was passed to the Coroner on the same day.
8. Mrs C says she contacted the Coroner’s office 47 times but her telephone calls were unanswered and she failed to receive a response to the numerous messages she had left. Mrs C says she did not know where Mr M’s body was, whether she would be required to identify him or what the process was.
9. Mrs C says she did not hear from the Coroner’s office until 19 March 2018, after she had submitted a complaint.
10. Mrs C says she received an email reply from the Coroner’s office on 20 March 2018 where it apologised and asked her to identify Mr M’s body as soon as possible because it was in a state of decomposition.
11. The Council upheld Mrs C’s complaint that there was a lack of reasonable contact with her and her family.
12. The Council apologised to Mrs C for the additional upset and frustration she experienced at such a difficult time due to the lack of contact and information she received from the Coroner’s Service. It also apologised for the upset caused to Mrs C and her family due to the delay in arranging for Mr M’s body to be identified and the distress caused by the decomposition.
13. It said that as the Council funds the Coroner’s Service, it is committed to supporting the Coroner in addressing the challenges being experienced by the service in order to minimise delay and improve the service offered to families.
14. The Council said the Coroner’s Service had experienced an extremely high volume of referrals which combined with a national shortage of pathologists, had contributed to delays in the administration of inquests.
15. The Council said it had proposed to undertake the following actions to improve the service it provided to families:
• Improve general call handling by adopting a more centralised approach with calls being taken through a single point of contact with dedicated call handlers.
• It is examining how to better use systems and automation so that families are able to find out information themselves about the status of an inquest which will reduce the need for them to have to contact the service.
• A review of the current Coronial service structure and processes to make sure resources are re-aligned and directed to where they are most needed.
• It was in the process of recruiting and training six Coroner’s support officers to add capacity to the team.
• It is producing new guidance to make sure only relevant cases are referred to the Coroner’s Service and changes are also being implemented to the referral process relating to deaths in hospitals to make sure that referrals are only made when required.
• The development and implementation of a fast track inquest process for appropriate cases is also being piloted.
• A new casework management system was introduced in late 2018 to improve case management.
• The Council is looking to identify and recruit new Pathologists.
• It is reviewing the feasibility of using alternative ways to establish cause of death i.e. non-invasive post mortems.
• The Coroner’s Service is also having frequent meetings between Pathologists and the Coroner to address any immediate or frequent concerns to ensure a strong working relationship.
16. The Council said it hoped the service improvements identified gave some reassurance to Mrs C that it was working hard to address the challenges it is facing in order to improve the service it offers bereaved families. The Council also said that it had listened to Mrs C’s concerns and taken them on board as part of the wider improvement work it was undertaking.
17. Mrs C was unhappy with the Council’s response and brought her complaint to the Ombudsman.

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Analysis

18. Mrs C asked the Council to take action in response to her complaint and asked for an assurance that no other family will have to go through the same strains and upset as they did.
19. The Council is in the process of making several service improvements to reduce delay and improve the service it offers to bereaved families. I am satisfied with the service improvements the Council has proposed and is in the process of implementing.
20. The Council has provided Mrs C with an apology for the distress and upset it has caused. It has also provided a detailed explanation about the process it followed, what to expect next and it also provided explanations for the delays and the poor service Mrs C and her family received.
21. I acknowledge the distress and frustration the family were caused as a result of the fault. But I am satisfied with the Council’s final response it sent to Mrs C and the action it is taking to ensure the faults do not reoccur.

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Final decision

22. There is fault by the Council and it has apologised to the family and taken action to address its failings and improve processes. My view is the Council’s proposed remedy is appropriate. I have completed my investigation into this complaint.

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Investigator's decision on behalf of the Ombudsman