Summary: We cannot investigate this complaint about the verdict of a Coroner because we have no jurisdiction over the decisions of coroner’s. We will not investigate comments made by staff working for the coroners service, because we could not add to the Council’s investigation or achieve the outcome she wants.

The complaint

1. The complainant, who I will call Miss X, complains about the Coroner’s decision on the inquest into the death of her son. She questions the verdict regarding the circumstances of her son’s death and points to errors during the proceedings. Miss X also complains about how she was dealt with during proceedings, by staff working for the coroner’s service.

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The Ombudsman’s role and powers

2. 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
• we could not add to any previous investigation by the organisation, or
• we cannot achieve the outcome someone wants.

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

3. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as Coroners where they are about the decisions of inquests. (Local Government Act 1974, sections 25 and 34A, as amended)

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How I considered this complaint

4. I considered information provided by the complainant and the Council.
5. I considered the Ombudsman’s Assessment Code.
6. The complainant now has an opportunity to comment on my draft decision. I will consider their comments before making a final decision.

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My assessment

7. We cannot investigate Miss X’s complaint about the verdict of the Coroner or about how the Coroner conducted the hearing. This includes which witnesses the Coroner chose to call or how much weight they gave to evidence heard during the hearing. We also cannot investigate or liaise with the Coroner about questions Miss X has about the Coroner’s findings. This is because we have no jurisdiction to investigate complaints about Coroner’s decisions and how they conducted an inquest.
8. I will not investigate Miss X’s complaint about how she was treated by staff working for the coroner’s service. This is because the Council has spoken to the staff member involved, and she and Miss X have very different recollections about what was said prior to the hearing. I was not privy to those discussions so I cannot rectify the conflicting views of what was said. Therefore, it is unlikely we could reach a meaningful conclusion on these matters.
9. Miss X questions why she was given a small room at the hearing, while other attendees were given larger rooms. The Council has explained that the other group of attendees had more members and needed changing facilities so were given a larger room. It is unlikely that any further investigation would find the coroners service at fault for this approach.
10. We also cannot achieve what Miss X wants, which is for the Coroner to change the inquest decision reached. The only way to challenge the decisions is by way of judicial review in the High Court. It is also possible to apply to the Attorney General under s.13 of the Coroners Act 1988.

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Final decision

11. We cannot investigate her complaint about the Coroner’s verdict because we have no jurisdiction to investigate the decision of coroners. We will not investigate the actions of the coroner’s service because we cannot add to the Council’s previous investigation and cannot achieve the outcome that Miss X wants.

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Investigator's decision on behalf of the Ombudsman