Summary: Mrs B complained about her contact with the Council’s coroner’s office. She said the staff were unprofessional and lied to her family. We did not find fault.

The complaint

1. Mrs B’s husband, Mr B, sadly passed away in 2021. Mrs B complained about the service from the coroner’s office and the conduct of coroners office staff. She complained:

• The coroners staff acted unprofessionally in their contact with the family.
• The coroner’s staff lied to the family about the independence of the pathologist who carried out the post-mortem.
• The coroner’s office caused delays releasing Mr B’s body to the family and this meant they could not arrange a second post-mortem.
• The coroner’s office discriminated against Mrs B’s son, Mr C, because it refused to communicate with him by telephone.

2. Mrs B said this caused her family distress at an already difficult time. She also said it prevented the family being able to have a second post-mortem.

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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. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
5. 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

6. I spoke to Mrs B and considered the information she provided with her complaint. I made enquiries with the Council and considered its response along with the relevant guidance.
7. Mrs B and the Council had the opportunity to comment on my draft decision. I carefully considered any comments I received before making my final decision.

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What I found

8. The Ombudsman has limited jurisdiction to look at complaints about the actions of coroners. Coroners are judicial office holders and not employees of the council. Coroners’ decisions can only be challenged by way of judicial review.
9. The service is funded by council’s which usually provide the coroner with administrative support. The Ministry of Justice publish a set of service standards which the coroner’s office should follow.
10. Generally, the Judicial Conduct Investigations Office deals with complaints about the personal conduct of coroners. It is possible that some complaints about a breach of the service standards could also be seen as a complaint about personal misconduct.

What happened

11. This is a brief chronology of key events. It does not contain everything I reviewed during my investigation. I refer to the coroner’s office as the Council because it is the body in jurisdiction.
12. Mr B sadly passed away in June 2021.
13. The post-mortem also took place in June. The family were not happy with the independence of the pathologist who carried out the post-mortem. They asked for a second post-mortem and complained to the Council.
14. The coroner told the family they would need to arrange the second post-mortem.
15. There was ongoing communication about the second post-mortem and complaint issues between Mr C, the coroner, coroner’s office staff and the family solicitor.
16. Mr B’s body was released to the funeral directors in mid-July 2021.
17. The coroner gave their final complaint response in July. They did not uphold Mrs B’s complaint.
18. Mrs B was unhappy with the response and complained to the Ombudsman.

My findings

19. I have summarised my findings under Mrs B’s complaint headings.

The coroners staff acted unprofessionally in their contact with the family

20. Mrs B says the coroner’s staff were unprofessional during her communication with them.
21. In response to our enquiries the coroners officer said:

“They (Mrs B and Mr C) have been repeatedly warned and despite this, the abusive language and behaviour has continued. Staff have remained professional, despite a number of the team being reduced to tears, by both Mrs C and Mr B.

As a result of the abuse, and also the threats… we took the step of contacting the police. We have never had to contact the police in this capacity before”.

22. I did not find fault with the way the coroners staff communicated with the family.
23. Contrary to what Mrs B said in her complaint the evidence suggests the coroners staff communicated with the family in a professional, courteous manner.
24. The coroners staff and the coroner responded to all the families queries and complaints. Mrs B and Mr C made it very challenging for the staff involved but they continued to provide the family with information and updates throughout the time they were involved following Mr B’s death.

The coroner’s staff lied to the family about the independence of the pathologist who carried out the post-mortem

25. Mrs B said the coroners staff wrongly told her and Mr C the pathologist was independent of the hospital where Mr B passed away. This was important to the family because they had a claim against the hospital in relation to the care Mr B received there.
26. I did not find fault with the Council. There was no evidence the coroners staff lied to the family about the independence of the pathologist.
27. Records showed the coroners staff spent a lot of time explaining the process and the role of the pathologist to Mr C.
28. In its complaint response the Council said it could have followed this up in writing to reduce the chance of misunderstanding. It said it will do this in the future.

The coroner’s office caused delays releasing Mr B’s body to the family and this meant they could not arrange a second post-mortem

29. Mrs B said the family wanted a second post- mortem but this was not possible because the coroner delayed releasing Mr B’s body to the family.
30. I did not find fault. The delay releasing Mr B’s body to the family was not caused by the coroners office.
31. The coroner and their staff explained the process for requesting a second post-mortem to the family in several emails and phone calls.
32. In response to our enquiries the Council said:

“Despite these great lengths, the family were reluctant to make a decision and we eventually took the step of releasing Mr B into the care of the family funeral directors…owing to the length of time taken for the family to agree to his release.

Any delays with the release of Mr B rest firmly with the family who were unwilling or unable to make a decision as to whether they were going to have a second post mortem”.

33. The evidence supports the Council’s summary of this part of the complaint.

The coroner’s office discriminated against Mr C because it refused to communicate with him by telephone

34. Mrs B said the Council discriminated against Mr C. She said he asked for communication by telephone because he is dyslexic. She said the Council refused to speak to him and communicated by email.
35. I did not find fault with the Council. The coroner and coroner’s office staff spent a lot of time on the phone to Mr C. They only stopped communicating with him by phone because he was abusive to them during the calls.
36. In response to my enquiries the Council said:

“You (Mr C) were warned on two separate occasions about communication and that, if it persisted, that it would have to be in writing with yourself. The decision to communicate with you in writing was only taken after warnings were not heeded.

This was done in line with the Cambridgeshire County Council policy entitled: ‘Customer Handling Policy’”.

37. Following this the Council explained it would communicate in writing and offered to liaise with the family solicitor. The Council said that since communication has been through the family solicitor there has been no further issues.

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Final decision

38. I did not find fault with the Council. I completed my investigation.

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Investigator's decision on behalf of the Ombudsman