Summary: Mrs Y complains about how the coroner’s office handled the inquest into the death of her late sister. We cannot investigate some of the matters complained about because they are outside of our jurisdiction. However, we found the coroner’s office failed to make an audible recording of the hearing, but this did not cause significant injustice to Mrs Y. We also found the coroner’s office did not disclose all relevant documents to Mrs Y and the Council failed to respond to Mrs Y’s complaint.

The complaint

1. The complainant, whom I will call Mrs Y, complains about the coroner’s handling of an inquest into the death of her sister.
2. Mrs Y says this caused avoidable frustration and distress and left her feeling that the coroner was biased towards the hospital where her sister died.

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What I have investigated

3. We have investigated Mrs Y’s complaint that she was unable to fully participate during the inquest because she could not hear the coroner. We have also investigated Mrs Y’s complaint that she did not receive an audible recording of the hearing and all documents she was entitled to.
4. We have not investigated Mrs Y’s complaint about the conduct of the coroner and the alleged bias for the reasons explained at the end of this statement.

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The Ombudsman’s role and powers

5. 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 another body better placed to consider this complaint (Local Government Act 1974, section 24A(6))
6. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
7. 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. We can consider whether the body in jurisdiction followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
8. 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

9. I discussed the complaint with Mrs Y and considered any information she submitted.
10. I made enquiries of the coroner’s office, via the Council, and considered its response. This included an audio recording of the inquest hearing.
11. I referred to the relevant law and guidance in force at the time of the matters complained about which I have referred to where necessary in this statement.
12. I considered any comments received in response to my draft decision statement.

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What I found

Key law and guidance

13. 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 who can be civilian employees or seconded police 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.
14. The Ministry of Justice (MoJ) publishes a guide to coroner’s services which sets out service standards and offers advice on how to complain about a coroner’s office. It says that if someone considers a coroner’s office has not met the service standards set out in the guide, they should first complain to that service. If dissatisfied, the person can then complain to the council and next, if still dissatisfied, to the Ombudsman. The guide distinguishes complaints about standards from complaints about a coroner’s personal conduct.

What happened during the hearing

15. In October 2020 Mrs Y and her husband, who I will call Mr Y, attended an inquest into the death of her sister. At the time of the hearing, the area was in a strict COVID-19 lockdown which meant that people had to stay home as much as possible and only leave their houses for specific and essential purposes. Social distancing rules in place at the time meant that people could only mix with those in their household or support bubble and had to maintain a social distance with anyone else.
16. Due to the strict measures in place at the time, the building where the inquest was held was closed to the public. Therefore, all witnesses and interested persons joined the inquest remotely except for Mr and Mrs Y. This is because Mr and Mrs Y had expressed that they were unable to attend the hearing remotely. The coroner made an exception to invite them in person.
17. An audio recording of the inquest reveals that Mr and Mrs Y were invited into the room at the start of the hearing and asked to sit at the back of the court. The coroner, who was using a microphone, checked the member of staff also stood at the back of the room was able to hear the proceedings. The staff member confirmed they could.
18. Six minutes into the hearing Mrs Y said she could not hear the coroner. The coroner invited Mrs Y to move forward slightly. Two minutes later Mrs Y again repeated that she could not hear the coroner, who invited Mrs Y to move again. The coroner apologised to the other attendees for the delay.
19. The coroner suggested that Mr and Mrs Y could sit on chairs in front of the press area. Mr and Mrs Y took their new seats and the coroner proceeded with the hearing. Several minutes later Mrs Y again expressed that she could not hear. The coroner invited Mrs Y to move again.
20. After the first witness had spoken Mrs Y again said she could not hear. The coroner asked whether Mrs Y used hearing aids. She confirmed she did not. The coroner checked the audio was on full volume and again confirmed with the officer at the rear of the room that her microphone could be heard.
21. The coroner suggested there was no more which could be done to assist and she asked whether Mrs Y would like to request an adjournment of the hearing. Mrs Y confirmed she did not wish to adjourn.
22. After the second witness had spoken the coroner asked Mrs Y whether she could hear. Mrs Y said she could hear the witness but still could not hear the coroner and commented that she did not feel like she was a part of the inquest.
23. The coroner explained that due to the strict COVID-19 measures in place at the time, she would not allow Mrs Y to move any closer to the front of the courtroom. After some discussion, Mr and Mrs Y agreed to move to another room to join the inquest remotely via a laptop. After a short adjournment to make the necessary arrangements, Mr and Mrs Y joined the inquest remotely and confirmed they could hear the coroner.
24. The coroner re-capped what had happened at the beginning of the hearing and then proceeded with the inquest. Mrs Y did not report any further problems.
25. As set out in the previous section of this statement, the LGSCO’s jurisdiction in the context of this complaint is limited. We can only consider whether the coroner acted in accordance with the general service standards outlined in the MoJ guidance. We cannot comment on the conduct of the coroner or their conclusions.
26. I find no fault with the standards of service provided during the hearing. I appreciate Mrs Y was disappointed to be sat so far from the coroner and expressed difficulty in hearing the proceedings. However, I do not find the problems which Mrs Y experienced were because of maladministration by the coroner’s office. It is clear from the audio recording that everyone except for Mrs Y could hear the coroner. The coroner’s voice is very clear on the recording. If there were problems with the acoustics of the room, then I would expect others to have expressed similar difficulties.
27. I note Mrs Y queried why she had to sit more than two meters from the coroner. The coroner explained it was not normal practice for interested people to attend in person during the COVID-19 lockdown, but that an exception was made for Mr and Mrs Y. The coroner was understandably concerned the transmission of COVID-19 to staff members would prevent the coroner’s office from fulfilling their important statutory duties. I do not criticise the coroner’s office for exercising caution in these circumstances.
28. Furthermore, I do not consider that Mrs Y experienced any significant injustice. The audio recording reveals that Mrs Y experienced problems at the beginning of the hearing when a witness read excerpts of documents already in Mrs Y’s possession. The second witness explained their reasons for amending the certified cause of death. The coroner adjourned the hearing and staff members acted promptly to assist Mrs Y in moving to an alternative room. The coroner re-capped with a summary of the evidence given by the first and second witness when Mrs Y re-joined the hearing remotely. I therefore find that Mrs Y did not miss a significant part of the hearing and was not prevented from participating.

What happened after the hearing

29. Mrs Y received an audio recording of the hearing in line with the requirements of the MoJ guidance which says, “All inquest hearings must be recorded, and you have a right to ask for a recording of proceedings”.
30. Mrs Y says the recording is inaudible. I have reviewed the audio recording of the hearing. Due to the witnesses attending remotely, there is an echo which makes some parts of the recording inaudible. There is no echo of the coroner’s voice which can be heard clearly throughout.
31. In my view, although most of the recording is clear, I find the coroner’s office has not strictly adhered to the MoJ guidance because I would expect the entire recording to be audible. However, I accept the coroner’s office did the best it could in the difficult circumstances to capture the audio of the hearing which was mostly attended by people joining remotely.
32. I also find that Mrs Y did not experience any significant injustice because the parts of the hearing which are not clear occurred after Mrs Y joined remotely and she did not express any problems with those parts of the hearing on the day. I am therefore satisfied Mrs Y has not missed any integral parts of the hearing due to any technical issues with the recording.
33. Furthermore, the office has since undertaken improvements to enhance the quality of recordings, so I am satisfied the office is unlikely to experience any further problems of this nature. I have not recommended anything further because in my view Mrs Y has not experienced significant enough injustice.
34. Mrs Y also complains she has not received a copy of a document which she is entitled to. The document in question is owned by a hospital trust and was referred to during the hearing. The MoJ guidance states, “As an interested person you will be given copies of documents that the coroner or other witnesses will use in the inquest, for example, medical records, witness statements and expert reports – this is called ‘disclosure’. You can also ask for copies to be sent to you at the pre-inquest review or you may be able to go to the coroner’s office to look at a document. If you do not receive documents that you think you have a right to, you should speak to the coroner’s office as soon as possible. The coroner’s office will not charge you for copies of documents they give you before or during the inquest, but they may charge for copies they give you after the inquest.”
35. The day after the hearing the coroner’s office wrote to Mrs Y with the ‘record of inquest’ and explained that it would notify Mrs Y once her sister’s amended death certificate was ready for collection. The coroner’s office also said it had asked the hospital trust to send a copy of the updated action plan to Mrs Y directly.
36. At the time of complaining to the LGSCO Mrs Y said she still had not received the updated action plan. Mrs Y is entitled to receive a copy because it was referred to in the inquest and is therefore a relevant document for disclosure. However, the document is held by the hospital trust and as explained during the hearing, must be shared with: Mrs Y, the Parliamentary Health Service Ombudsman (PHSO) and Care Quality Commission (CQC). The coroner’s office asked the trust again in February 2022 to disclose the document to Mrs Y.
37. In line with the guidance, the coroner’s office should ensure that Mrs Y receives a copy of the updated action plan and I have made a recommendation to reflect this.

Complaint handling

38. The MoJ guidance makes clear that the person affected may complain to the Council: “If you have a complaint about the way a coroner or their staff handled an investigation (for example, if you feel the standards in this Guide are not being met), you should first write to the coroner, and send a copy of your letter to the local authority which funds the coroner service… You may also complain to the local authority which funds the coroner service you are dissatisfied with. If you are unhappy with the local authority’s response, you have a right to complain to the Local Government Ombudsman about how the local authority dealt with you although the Local Government Ombudsman cannot review or alter a coroner’s decision”
39. Mrs Y sent her first complaint directly to the coroner’s office. She was entitled to take this course of action. When she remained dissatisfied, Mrs Y wrote to the Council in September 2021. The Council did not respond to Mrs Y’s complaint and instead forwarded it to the coroner’s office who reiterated there was nothing further to add to the response already provided.
40. I find fault with the Council’s handling of Mrs Y’s complaint. Mrs Y followed the procedure as set out in the guidance; she first complained to the coroner’s office, and then to the Council. The Council should have responded to Mrs Y’s complaint but instead forwarded it back to the coroner’s office without further explanation. I consider this caused Mrs Y some avoidable frustration which the Council will apologise for.

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Agreed action

41. Within four weeks of my final decision, the Council will:
• Apologise to Mrs Y for failing to respond to the complaint she made to the Council in September 2021; and
• Remind its officers of the requirement to respond to complaints made to the Council about the standards of the coroner’s office.
42. Within four weeks of my final decision, the coroner’s office will:
• Ensure that Mrs Y receives a copy of the hospital’s updated action plan as referred to during the inquest touching upon the death of Mrs Y’s sister.

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Final decision

43. We have not found fault in the substantive matters complained about. Some of the other matters are outside of the LGSCO’s jurisdiction. However, the Council failed to respond to Mrs Y’s complaint and the coroner’s office did not ensure that Mrs Y received all the documents she was entitled to. The Council and the coroner’s office will provide the remedy we recommended above.

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Parts of the complaint that I did not investigate

44. We have not investigated Mrs Y’s complaint about the coroner’s conduct and her allegation that they made unprofessional comments during the hearing. This is because Mrs Y had a right to complain to the Judicial Conduct Investigations Office (JCIO). The JCIO is the appropriate body to consider complaints about the conduct of a coroner.
45. We cannot investigate any concerns Mrs Y has about the outcome of the hearing and the possibility of bias in the decision making. This is because inquest outcomes can only be challenged via Judicial Review (JR).

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Investigator's decision on behalf of the Ombudsman