Surrey County Council (21 009 310)

Category : Other Categories > Other

Decision : Upheld

Decision date : 11 Mar 2022

The Ombudsman's final decision:

Summary: Mrs X complained about how the Council managed the Coroner’s inquest into her father’s death. The Council was at fault when it both failed to invite Mrs X to the inquest and provide her with important documents prior to it. It meant Mrs X did not attend the inquest into her father’s death and lost the opportunity to ask relevant witnesses questions. The Council agreed to pay Mrs X £300 to recognise the distress, frustration and uncertainty this caused.

The complaint

  1. Mrs X complained about how the Council managed the Coroner’s inquest into her father’s, Mr T’s death. Mrs X said the Council did not invite her to attend the hearing, the Council’s communication was poor and it did not obtain important information. Mrs X also complained the Council’s response to her complaint was inadequate. Mrs X stated this caused her and her family distress and she had to take legal advice to understand the process.

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What I have investigated

  1. I have investigated the actions of the Council’s Coroner’s office. I have not investigated the decisions made by the Coroner. I have provided a further explanation in paragraph 33.

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The Ombudsman’s role and powers

  1. 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)
  2. 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

  1. I read the documents provided by Mrs X and discussed the complaint with her on the telephone.
  2. I considered the Council’s responses to Mrs X’s complaints.
  3. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

  1. 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. The Ministry of Justice published a guide to Coroner’s services which sets out service standards. This should be provided to families who are involved in a Coroner’s inquest. The standards 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 give you copies of relevant documents before the inquest.
  2. 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.
  3. But the service is funded by Local Authorities and usually the authority provides the Coroner with administrative support, usually known as the Coroner’s office. The actions of the Coroner’s office is therefore the responsibility of the Council. In this case I will refer to the Coroner’s office and the Council separately to explain what happened.

What happened

  1. In July 2020 Mrs X’s father, Mr T died in hospital. Due to the circumstances of his death the Coroner ordered a post-mortem and inquest to establish the cause of Mr T’s death.
  2. In October the Coroner opened an inquest and the Coroner’s office began gathering the relevant evidence and witness statements.
  3. In February 2021 the Coroner’s office shared a bundle of statements for the inquest hearing with Mrs X. It asked Mrs X to tell it if she had any queries about the statements. It also told Mrs X there was a provisional hearing date in Spring 2021.
  4. Mrs X reviewed the statements with her family members and found some inaccuracies in the statements. She sent her concerns and queries about the inaccuracies to the Coroner’s office two weeks later. Mrs X sent a follow up email one week later but did not receive a substantive response to either email.
  5. The Coroner held the inquest hearing on the provisional date in Spring 2021, made their findings and closed the inquest. Mrs X was unaware the hearing was being held and therefore did not attend. When Mrs X found out the Coroner had held the hearing, she asked for an audio recording of the hearing. The Coroner’s office gave her a copy of the recording and the full bundle of documents the Coroner considered.
  6. Mrs X complained to the Coroner’s office in April 2021. She said she did not dispute the result of the inquest. She complained that:
    • the Coroner’s office had not confirmed the date of the hearing and she was denied the opportunity to attend and ask questions of the witnesses;
    • she had identified factual errors in the recording of the inquest that she wanted corrected;
    • her email of February which raised concerns and inaccuracies in the statements was not considered at the hearing; and
    • the Coroner’s office had not provided her with all the statements referred to until after the hearing and so she could not dispute them.
  7. In May the Coroner’s office responded to Mrs X’s complaint. It apologised for its administrative failures and the distress and unhappiness it caused. It explained the Coroner could not legally revisit or re-open their decision once they had closed an inquest, unless it was required to do so by a judicial review. It advised Mrs X to seek legal advice if she wanted to challenge the conclusion or seek a fresh inquest.
  8. Dissatisfied with the Coroner’s office response Mrs X complained to the Council. She raised the same points of complaints as to the Coroner’s office plus:
    • the Coroner’s office had only given her the ‘Guidance to the Coroner’s Service’ booklet after the inquest had concluded;
    • the service from the Coroner’s office was poor with little communication and changes in case officers without notice;
    • the Coroner’s office had not asked her to consent to a documentary hearing; and
    • the Coroner’s office complaint handling and process was unclear.
  9. The Council responded to Mrs X and explained it could consider part of her complaint. It stated it could not consider matters that were judicial conduct or judicial process. It said it could not consider:
    • the inaccuracies in the recording of the hearing, or how they would be corrected;
    • that the Coroner had not given Mrs X the opportunity to comment on all the statements before the hearing; and
    • the Coroner did not consider the inaccuracies Mrs X identified in the statements which she sent in February.

The Council signposted Mrs X to the Judicial Conduct Investigations Office (JCIO) for the matters it could not consider.

  1. In June the Council provided a response to the other parts of Mrs X’s complaint. It accepted that:
    • the Coroner’s office had not confirmed the date of the inquests to Mrs X, gathered her consent for a documentary hearing or provided her with all the relevant documents;
    • the Coroner’s office did not bring Mrs X’s email raising inaccuracies in the statements to the attention of the Coroner before the hearing;
    • the case handling, communication and turnover of case officers was poor service and Mrs X did not receive the guidance booklet at the earliest opportunity; and
    • her complaint experience was not at the standard expected.
  2. The Council apologised for the distress caused to Mrs X and set out the service improvements it had made because of her complaint. It said the Coroner’s office had:
    • updated its operating procedures and introduced mandatory tasks for case officers. The tasks would ensure it communicated information to families at the appropriate times and there would be full disclosure of documents before an inquest;
    • developed training for all staff on case management, information sharing and updating of bereaved families; and
    • revised its procedures for complaint handling within the Coroner’s office and had recruited additional staff with responsibility for complaints.
  3. In September 2021 Mrs X made a further complaint to the Coroner’s office. Mrs X requested the Coroner wrote an addendum to the inquest paperwork to outline errors and corrections she had identified. Mrs X also asked the Coroner to identify what would have happened if the correct process had been followed.
  4. In October the Coroner’s office responded to Mrs X. It said as the Coroner could not amend the record of inquest it could not agree to Mrs X’s request.
  5. Mrs X asked the Coroner’s office if the Coroner could issue an informal letter or statement to cover matters which would not form part of the legal inquest paperwork. Mrs X states she did not receive a reply to this request.
  6. Dissatisfied with the Council and Coroner’s office responses Mrs X complained to us. Mrs X also raised a complaint about the Coroner’s actions with the JCIO.
  7. In response to my draft decision the Council stated it was not in its remit to request the Coroner to issue a formal letter or statement as outlined at paragraph 22. This was because the Coroner is an independent judicial office holder. The Council also stated it could not comment on whether the family’s presence would have materially affected the outcome of the inquest.

My findings

  1. Mrs X was an interested party. In line with the service standards the Coroner’s office failed to provide Mrs X with all the relevant statements before the inquest hearing and failed to tell Mrs X the confirmed date of the hearing. That was fault and not in line with the service standards. It meant Mrs X could not attend and she lost the opportunity to ask the questions she needed to understand the circumstances surrounding her father’s death. It caused Mrs X distress and uncertainty.
  2. The Coroner’s office also failed to provide Mrs X with regular and meaningful updates on both Mr T’s inquest and on her complaint about the matter. Its communication with Mrs X was not at the standard expected for the service. That was fault and caused Mrs X further distress and frustration.
  3. Some of Mrs X’s complaint related to the conduct of the Coroner themselves or the judicial decisions they made. The Council correctly referred Mrs X to the JCIO which is the appropriate body to investigate complaints about a Coroner. There was no fault in the Council’s actions and as the conduct of the Coroner is outside of our jurisdiction, I have not looked at this any further.
  4. Although Mrs X does not disagree with the outcome of the inquest she is left with unanswered questions about the circumstances of her father’s death. The Council has apologised to Mrs X for the injustice caused by the faults identified above. It has also outlined the service improvements it has carried out which is an appropriate remedy to avoid the faults happening in other cases. I have made a further recommendation to remedy the injustice the faults caused Mrs X.

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Agreed action

  1. Within one month of the final decision the Council will:
    • pay Mrs X £300 to recognise the distress and uncertainty caused to her by the administrative failings of the Coroner’s office; and
    • provide us with evidence it has completed the service improvements it has implemented as outlined in paragraph 21.

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Final decision

  1. I have completed my investigation. I found fault leading to injustice and the Council agreed to my recommendations to remedy that injustice.

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Parts of the complaint that I did not investigate

  1. I have not investigated the decisions made by the Coroner or their conduct. These included the decision to hold a documentary hearing, who was invited to give evidence, when the inquest hearing was held, and its result. Coroners are independent judicial office holders, and their decisions can only be challenged by judicial review. Mrs X has already made a complaint to the JCIO.

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Investigator's decision on behalf of the Ombudsman

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