Summary: Mr and Mrs F complained about the Coroner’s Offices administration of an inquest into the death of Mr G. Mr and Mrs F said the problems they experienced with the Service caused them distress and financial loss. There was fault with the Coroner’s Service’s complaint response. We do not consider this to have caused Mr and Mrs F significant injustice.

The complaint

1. The complainants, who I shall refer to as Mr and Mrs F, complained the Coroner’s Office:
• did not invite all relevant people to give evidence at Mr G’s inquest;
• accepted witness statements that were wrong;
• delayed asking for evidence;
• mislaid evidence;
• did not follow COVID-19 regulations when visiting them at home; and,
• did not follow its complaints procedure.
2. Mr and Mrs F said the problems they experienced with the service caused them upset and distress. They say they were put to time and trouble because they had to carry out their own investigation into Mr G’s death. They reported that they also lost out financially because they had to pay for a barrister to represent them at the inquest.

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What I have investigated

3. I have not investigated the following:
• Decisions made by the Coroner. These included who was invited to give evidence, when the inquest hearing was held, and its outcome. Coroners are independent judicial office holders, and their decisions can only be challenged by judicial review. Mr and Mrs F have made a complaint to the Judicial Conduct Investigations Office.
• Mr and Mrs F’s concerns that witness statements were incorrect. Concerns about evidence provided to the inquest should have been raised at the inquest hearing.
• Whether staff from the coroner’s service followed COVID-19 regulations when visiting Mr and Mrs F at home. This is a new complaint.
4. I have investigated whether the Coroner’s Office delayed asking for and lost evidence, delayed sending evidence to Mr and Mrs F, and followed its complaint procedure.

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The Ombudsman’s role and powers

5. 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)
6. The courts have said that where someone has used their right of appeal, reference or review or remedy by way of proceedings in any court of law, the Ombudsman has no jurisdiction to investigate. This is the case even if the appeal did not or could not provide a complete remedy for all the injustice claimed. (R v The Commissioner for Local Administration ex parte PH (1999) EHCA Civ 916)
7. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
8. The law says we cannot normally investigate a complaint unless we are satisfied the council knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the council of the complaint and give it an opportunity to investigate and reply (Local Government Act 1974, section 26(5))
9. 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

10. I considered:
• Mr and Mrs F’s complaint and the information they provided;
• documents supplied by the Council;
• relevant legislation and guidelines; and
• the Council’s policies and procedures.
11. Mr and Mrs F and the Council commented on a draft decision. I considered their comments before making a final decision.

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What I found

Legislation and Guidance

12. 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. 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.
13. 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 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.
14. The Ministry of Justice published a guide to coroner’s services which sets out service standards. These include:
• The coroner’s office will contact you regularly. In a long investigation they will contact you at least every three months to update you on your case (unless you only want to hear if there is any progress to report).
• The coroner’s office must tell you the date and time of the inquest and where it will be held within a week of fixing the inquest. The coroner’s office will consider your views on the date and time of the inquest whenever possible.
• If you are an interested person, the coroner should have give you copies of relevant documents before the inquest.
15. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. The Chief Coroner issued guidance to coroners in March 2020 on COVID-19. The guidance said coroners should recognise medical professional’s primary clinical commitments especially at times of high pressure on the health service. It said this may mean avoiding or deferring requests for statements and granting extensions. (Chief Coroner, Chief Coroner’s Guidance on COVID-19, March 2020)
16. The Coroner’s Service did not hold in person inquest hearings between 23 March 2020 and 29 June 2020 because of COVID-19 restrictions. From 29 June 2020, the Service was able to hold inquest hearings with a maximum of seven people in attendance. From 21 September 2020, the Coroner’s Service was able to accommodate 14 people at an inquest hearing.
17. The Coroner’s Office’s complaint policy has two stages.
• At stage one the service will let complainants know their complaint has been received within three working days. It will provide a full response within ten working days or explain why it might take longer. In its response it will tell the complainant how to take their complaint further if they are still unhappy with the result.
• At stage two the service manager will tell complainants their complaint has been received within five working days. It will provide a full response within ten working days or explain why it might take longer.

What happened

18. This chronology includes key events in this case and does not cover everything that happened.

Inquest

19. Mr G passed away in April 2020. The Coroner opened an inquest into his death. Mr G was Mrs F’s father.
20. The Coroner’s Service wrote to Mr and Mrs F. It explained the inquest process and function. It told Mr and Mrs F it was not holding inquest hearings if witness had to attend in person, because of COVID-19. The Service shared Mr G’s post-mortem and witness statements with Mrs F.
21. In June 2020, Mrs F asked for an update. The Coroner’s Office told Mrs F the Coroner was waiting to receive further reports. It said it would tell her when the Coroner had listed Mr G’s inquest.
22. Mrs F queried why the Coroner was waiting for reports because the deadlines for these had passed. The Coroner’s Service advised:

“A complicating feature at the present time is, of course, the current Coronavirus crisis. As you will readily appreciate, hospital staff have been stretched dealing with the challenge of Covid 19 cases. The Senior Coroner sought to assist the hospitals in his area by indicating that the provision of statements for Inquests is a lesser priority than treating patients and hence the time for clinicians’ statements to be provided has been relaxed.”

23. The Coroner and the Coroner’s Service told Mrs F she could take independent legal advice if she wished.
24. In July 2020, Mrs F told the Coroner’s Service she was unhappy it had given medical staff longer to submit their witness statements. The Service chased the outstanding statements.
25. Mrs F raised queries with the Coroner’s Service about the content of some of the witness statements. The Service raised these matters, often the same day, with the authors of the statements and/ or the organisations they worked for.
26. The Coroner’s Service sent further medical reports and witness statements to Mrs F. Mrs F raised concerns about the content of these documents.
27. The Service collected evidence from Mrs F, made a copy and returned it within ten working days. Mrs F asked the Coroner’s Service for the Coroner’s view of the evidence she provided. She also asked for an update on the outstanding reports. The Service explained the Coroner did not have time to consider her evidence at present and would review the file in its entirety when he had received the outstanding statements. The Service said it had no updates on the timescales for these statements. It explained its case management protocol was to chase outstanding evidence if it was not received within four weeks of the request.
28. Mrs F raised queries about medical reports and statements with the Coroner’s Service. The Coroner’s Service raised these with the Coroner and/ or relevant medical professionals/ organisations. Often the Service did this on the day Mrs F raised the query. The Service promptly sent Mrs F the responses it got to her queries.
29. In August 2020, Mrs F asked the Coroner’s Service for an update for the outstanding reports and statements. The Service continued to chase the outstanding statements and explained to Mrs F why they were delayed, for example, staff absence.
30. The Coroner’s Service sent Mrs F further witness statements. Mrs F raised concerns about their content. The Service went back to the organisation who had sent them and advised the statements were incomplete. It gave the organisation two weeks to provide complete statements.
31. In September 2020, the Coroner sent Mrs F a copy of his inquest directions. The Coroner outlined the scope of the inquest, shared a draft witness list, and identified the evidence he needed to get. The Coroner asked witnesses to tell him if there were any dates they were not available between October 2020 and February 2021 to attend an inquest hearing.
32. Mrs F asked for an update on the outstanding evidence. The Service advised it would follow this up.
33. The Coroner’s Service sent Mrs F evidence it received. She raised concerns about the content of these witness statements and reports. The Service confirmed it would share her concerns with the Coroner.
34. The Service told Mrs F it was looking to book Mr G’s inquest on the first Monday in November. Mrs F said she could not confirm whether she was available on this day. Mr F told the Service he worked on Monday’s and asked it to hold the inquest on a Friday. He advised that as a last resort he would take a day of annual leave.
35. The Coroner’s Service sent Mrs F the outstanding evidence. Mrs F challenged the witness statements and queried whether a medical professional had the information he needed to make his statement. The Coroner advised Mrs F she could seek a second opinion. The Service confirmed the Coroner intended to hear the inquest of Mr G on the first Monday in November 2020.
36. Mrs F told the Coroner’s Service she wanted to amend her own witness statement and could not do this until she had seen all the evidence. She also told the Service she was unavailable on the date set for Mr G’s inquest. The Service told Mrs F the Coroner would write to her.
37. Mrs F told the Service she was trying to get legal representation. She asked it how long she had to do this and reiterated that she had said she was not available on the first Monday in November.
38. In October 2020, the Coroner issued Mr and Mrs F with witness summons to attend the inquest.
39. Mrs F again raised concerns the Service had not given evidence to a medical professional to inform their witness statement. The Coroner’s Services raised the concern with the Coroner. The Coroner decided these matters would be considered at the hearing. The Service updated Mrs F.
40. The Coroner’s Service supported Mrs F to update her witness statement. It sent her information about the inquest hearing, parking and arranged for her to have access to a room she could use on the day.
41. The inquest hearing was held in November 2020.

Complaint procedure

42. Mrs F complained to the Coroner’s Service in July 2020 about the sufficiency and timeliness of the investigation, the timeliness of information being sent to her and that she was not supported to write her witness statement. The Service Manager apologised for any failures to respond to her. In response to the complaint, the Service Manager took over the case and became Mr and Mrs F’s first point of contact.
43. Mr and Mrs F complained to the Council in October 2020. They complained about the Coroner and the Coroner’s Service. The Council told Mr and Mrs F it could not consider complaints about the Coroner and signposted them to the Coroner’s complaint procedure. The Council also said they could make representations at Mr G’s inquest hearing.
44. The Council considered complaints about the Coroner’s Service delays and failure to follow its complaint procedure.
45. The Council told Mr and Mrs F the service standard was for the Coroner’s Service to be in contact regularly, and in lengthy investigations, at least every three months. The Council explained the Service often responded to Mr and Mrs F the same day and sometimes multiple times in a day. It explained the investigation was a dynamic process and evidence was usually collected over time. The Council said the Service had diligently followed up further lines of enquiry at their request. It also confirmed the Service passed queries raised by Mrs F on to the Coroner. The Council said the Service met the service standards.
46. The Council apologised that the Coroner’s Service had not sent a written response to their complaint in July 2020. It explained this was because the Service focused on providing a service and addressing their concerns about the sufficiency of the investigation.
47. Mr and Mrs F responded and complained the Coroner’s Service:
• did not follow its complaint procedure;
• did not tell her of delays in the investigation;
• delayed asking for evidence;
• did not address her concerns about evidence being inaccurate; and
• held Mr G’s inquest without her concerns being answered.
48. The Council accepted the Service did not follow the complaint procedure at stage one. The Council said this did not impact on Mr G’s inquest hearing. It advised it could not deal with her concerns about the overall conduct of the hearing, or the evidence presented as these were matters for the Coroner. It explained she could raise these issues at the hearing.

Analysis

49. The Coroner’s Service works for the Coroner. Decisions made by the Coroner were out of my jurisdiction.
50. The Coroner decided what evidence to collect. The Service started to collect evidence as soon as the Coroner opened the inquest into Mr G’s death. The Service was proactive and asked for standard pieces of evidence. The Coroner reviewed this evidence and told the Service what else was needed. The Service sent the evidence it obtained to Mr and Mrs F as soon as it was received in an acceptable format. There is no evidence the Coroner’s Service delayed asking for or mislaid any evidence.
51. There was a delay in some organisations and professionals providing witness statements. In these cases, the Coroner’s Service chased the organisations and kept Mr and Mrs F regularly updated. The Coroner explained to Mr and Mrs F that medical staff were stretched because of the COVID-19 pandemic and providing statements was less of a priority than treating patients. It was the Coroner’s decision to grant medical professionals extensions in line with guidance from the Chief Coroner. Decisions made by the Coroner were outside my jurisdiction.
52. When Mrs F raised concerns about the accuracy of witness statements, the Coroner’s Service promptly fed these concerns back to the Coroner and raised them with the individuals or organisations concerned. It was not the Coroner’s Service’s responsibility to interrogate the evidence it received. This was a matter for the Coroner and the inquest hearing.
53. The Coroner’s Service asked Mr and Mrs F about their availability for the inquest hearing before a date was set. Mr and Mrs F did not confirm they were unable to attend on the proposed date until after the hearing was arranged. Ultimately, it was the Coroner’s decision when to hold the inquest and this decision was out of my jurisdiction.
54. The Coroner’s Service did not send Mr and Mrs F a written response to their July 2020 complaint, and this was fault. This fault was not considered to have caused Mr and Mrs F significant injustice because their concerns were addressed by the Service and following the complaint, it met its service standards.

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Final decision

55. I have completed my investigation. I found fault with the Coroner’s Service, however, I do not consider this to have caused Mr and Mrs F significant injustice.

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Parts of the complaint that I did not investigate

56. I did not investigate who the Coroner decided to invite to give evidence at the hearing. Coroners are independent judicial office holders, and their decisions can only be challenged by judicial review.
57. I did not investigate Mr and Mrs F’s concerns that witness statements were incorrect. Concerns about evidence provided to the inquest should have been raised at the hearing.
58. I did not investigate whether staff from the coroner’s service followed COVID-19 regulations when visiting Mr and Mrs F at home. This is a new complaint.

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Investigator's decision on behalf of the Ombudsman