Summary: Mr X says the actions of the Coroner and the Coroner’s office frustrated the investigative process into the cause of death of his mother. The complaint was closed because the injustice caused to Mr X is not so great that the Ombudsman would recommend a remedy.

The complaint

1. I refer to the complainant here as Mr X. Mr X says the actions of the Coroner and the Coroner’s office frustrated the investigative process into the cause of death of his mother.
2. Mr X says:
• The efforts of his family to seek justice for his mother were affected by the errors, mistakes, intransigence and gross ineptitude of the Coroner’s office which frustrated the veracity of the investigative process.
• His family received an email from the Coroner’s office 48 hours after his mother’s death which asked whether his brother was a qualified medical doctor. The approach of the office to their case changed when it established his brother is medically qualified.
• There was no visible record of the autopsy report being opened and adjusted on the document by the pathologist after the case had been closed by the Coroner.
• The family argued against the pathologist and succeeded in adjusting the cause of death in part 1c of the autopsy report.
• The family spotted factual errors in the first autopsy report rather than the Coroner’s office.
• The family alerted the Coroner to a medical typographical error which was corrected after the case had been closed and the change is still not evidenced in the document.
• The Coroner’s office used private ‘off the record’ phone calls to the family to conduct official, disputed Coronial matters.
• The family received four iterations of the autopsy report over a three month period with three corrections/additions/refinements but only two are evidenced in the document.

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The Ombudsman’s role and powers

3. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• any injustice is not significant enough to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint,
• it would be reasonable for the person to ask for a council review or appeal.

(Local Government Act 1974, section 24A(6))

4. The Ombudsman has limited jurisdiction to look at complaints about the actions of coroners. Coroners are judicial office holders and not employees of a council. Coroners’ decisions can only be challenged by way of judicial review.
5. There is a set of service standards which the coroner’s office should follow, and these are sent out in a booklet to people using the service.
6. Generally, the Judicial Conduct Investigations Office deals with complaints about the personal conduct of coroners, for example that they were rude, discourteous, or used inappropriate language. It is possible some complaints about a breach of the service standards could also be seen as a complaint about personal misconduct.
7. Separately, if a person has a complaint about the way the coroner or their staff handled an investigation, they should first write to the coroner and send a copy of their letter to the local authority which funds the coroner service. They can also complain to the local authority which funds the service and, if unhappy with the authority’s response, they can complain to the Local Government and Social Care Ombudsman.
8. We cannot get involved in any dispute about the outcome of an inquest or the findings of a post-mortem which should be challenged by way of judicial review. Neither can we deal with a complaint about the personal conduct of a coroner or get them dismissed. Complaints of that nature should be made to the Judicial Conduct Investigations Office.

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How I considered this complaint

9. I considered the complaint and information provided by Mr X. I considered the Ombudsman’s jurisdiction and the Ministry of Justice guidance on use of the coroner’s service. I discussed matters with Mr X by telephone.
10. I sent a draft decision statement to Mr X and the Council and considered the comments of both parties on it.

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What I found

11. The grounds of complaint as made by Mr X incline me to find the complaint is outside the Ombudsman’s jurisdiction. The complaint should instead be made to the Judicial Conduct Investigations Office.
12. But the grounds of complaint also hint at breaches of the service standards for coroners although they do not explicitly reference the service standards. In that case, the complaint could be considered by the Ombudsman.
13. It is unclear and so I have decided to treat the complaint as being within the Ombudsman’s jurisdiction.
14. When the death of Mr X’s mother was reported to the Coroner’s office, a cause of death was given by the attending medical staff. Mr X and his family contacted the police to challenge the stated cause of death. The Police, in turn, contacted the Coroner’s office. Mr X alleged there was clinical negligence and criminality involved. Mr X challenged the pathologist’s report and so there were three versions before a final report was issued.
15. When the coroner finally concluded the investigation, the final form did not include the pathologist’s amended cause of death. The coroner apologised for the mistake and the form was amended.
16. There is admitted fault by the coroner’s office in terms of its administration of the matter. And the injustice? I do not find the identified fault caused Mr X an injustice that now warrants further pursuit of the matter by, or a remedy from, the Ombudsman. The coroner apologised for the error and took action to correct it.
17. As to the other allegations of misconduct or administrative fault by the coroner and the coroner’s office listed here by Mr X, I do not find these are matters that caused significant injustice to Mr X and his family to the extent that they warrant further investigation by the Ombudsman. I shall deal with them in turn.

His family received an email from the Coroner’s office 48 hours after his mother’s death which asked whether his brother was a qualified medical doctor. The approach of the office to their case changed when it established his brother is medically qualified.

18. The coroner explained he enquired into the status of Mr X’s brother because he wondered whether Mr X’s brother would have insights into the alleged negligence in the medical treatment of Mr X’s mother stated in the emails the coroner office’s received from Mr X. That the question was asked by the coroner does not lead me to conclude there was a breach of the service standards. On the other hand, if Mr X considers there was personal misconduct by the coroner because his office asked the question then he can complain to the Judicial Conduct Investigations Office.
19. Mr X alleges the approach of the coroner’s office changed because they discovered his brother was medically qualified. The Council, on the other hand, says the Coroner’s approach did not change because of Mr X’s brother’s qualifications.
20. I cannot establish that there was any change given the short period of time between Mr X’s mother’s death and the question from the coroner’s office on the qualifications of Mr X’s brother. This was a period of 48 hours. There is no evidence to suggest the coroner’s office had an approach in that period that subsequently changed.

There was no visible record of the autopsy report being opened and adjusted on the document by the pathologist after the case had been closed by the Coroner; The family argued against the pathologist and succeeded in adjusting the cause of death in part 1c of the autopsy report; The family spotted factual errors in the first autopsy report rather than the Coroner’s office

21. These matters involve errors by the pathologist rather than the coroner’s office. Serious complaints can be made to the General Medical Council.
22. I do not find that the family spotting factual errors in the first autopsy report rather than the coroner’s office amounts to fault by the coroner. Mr X wrote to the coroner to challenge the stated cause of death of his mother. This led the coroner to refer the matter to the pathologist.
23. It was not unreasonable for the coroner to rely on the findings of the pathologist. I accept Mr X’s further challenges to the pathologist’s findings led to amendments of the pathologist’s report. But this does not mean there was administrative fault by the coroner.

The family alerted the Coroner to a medical typographical error which was corrected after the case had been closed and the change is still not evidenced in the document

24. If there is a typo which has not been corrected in the document then there is a question as to whether the typo is significant. If the typo is significant, for instance, Mr X finds that other procedures linked to the death of his mother cannot proceed because of the typo, then it is now for the coroner’s office to correct the typo. If the typo is not significant, then I do not find the document needs amendment now.

The Coroner’s office used private ‘off the record’ phone calls to the family to conduct official, disputed Coronial matters

25. I am uncertain what amounts to ‘off the record’ telephone calls to the family. The Council emphasises the Coroner made telephone calls in his official capacity out of concern for, and to provide pastoral support to, the family. It says no telephone calls were made off the record.
26. I do not find Mr X and his family suffered an injustice because they received private telephone calls from the coroner’s office.

The family received four iterations of the autopsy report over a three month period with three corrections/additions/refinements but only two are evidenced in the document

27. If the autopsy report is deficient because it had to be changed and the final report did not include two changes then Mr X had a right to seek a judicial review of the coroner’s findings. That was the appropriate means of challenging the coroner’s investigation.
28. In terms of the complaint now made to the Ombudsman, I do not find any omission in the final autopsy report caused significant injustice to Mr X and his family to now warrant a remedy from the Ombudsman.

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Final decision

29. There was fault in the administration process of the Coroner’s office. The identified fault did not cause Mr X and his family significant injustice to warrant further pursuit of this complaint by, or a remedy from, the Ombudsman.

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Investigator's decision on behalf of the Ombudsman