Summary: Mr X complains the Council has not dealt with his father’s death properly. The Council is at fault because it did not provide information, took too long to allocate a Coroner’s Officer and did not offer the opportunity to view the body. The Council has agreed to apologise to Mr X, pay Mr X £100, provide information and provide guidance to staff.

The complaint

1. The complainant, whom, I shall refer to as Mr X, complains the Council did not properly deal with his father’s death and did not follow the coroner’s guidance handbook because:
• it delayed making initial contact;
• there was poor communication from coroner and a lack of information provided;
• he wasn’t given the opportunity to visit the body; and
• it delayed release of the body.
2. Mr X says this caused him distress.

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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. 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)
5. If we are satisfied with an organisation’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 Mr X about his complaint. I made enquiries of the Council and considered its response and the supporting documents it provided.
7. Mr 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

Law, guidance and policies

8. When a death is reported, the coroner first carries out enquiries to see if they can find the cause of death quickly. If they can, and the death was due to natural causes, in most cases the coroner has no further role.
9. If the cause of death is still not known or appears unnatural or violent, the coroner investigates to find out the cause of death. This may include a post-mortem.
10. A close relative or the personal representative of the person who has died is considered to be an ‘interested person’. (s 47(2) of the Coroners and Justice Act 2009)
11. The Guide to Coroner’s Services for Bereaved People states the coroner’s office will:
• explain the role of the coroner and answer your questions;
• provide a contact in the coroner’s office throughout the investigation, including their phone number and/or email address;
• tell you about your rights and responsibilities;
• let you know when and where hearings will take place;
• give you documents and evidence that other interested persons have given the coroner (as far as possible);
• wherever possible, take account of your views, including your preferences, traditions and faith-based needs with regard to mourning, post-mortem and funerals;
• during a long investigation, contact you at least every three months, or sooner if further information is available, to update you on the progress of your case, and explain reasons for any delays; and
• explain why the coroner intends to take no further action in your case, if relevant
12. Interested persons have certain rights during the coroner’s investigation. These include to view the body of the person who died and be told the details of any post-mortem that might take place.
13. The Coroner has legal control of the body while they carry out their investigation. They will release the body as soon as possible and must tell interested persons the reasons for any delay if the body cannot be released within 28 days.
14. Specific standards of service are set out throughout the guide.

What happened?

15. 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.
16. Mr X’s father passed away in August 2021. The Council contacted Mr X the following day.
17. Mr X did not receive any update and contacted the Council in late August. His father’s case had not been allocated to a Coroner’s Officer at this time.
18. Several days later a Coroner’s Officer was allocated and they contacted Mr X.
19. A post-mortem was carried out in early September 2021 and arrangements were made for his father’s body to be released the following day.
20. Mr X complained to the Council. The Council gave their final complaint response in November. They did not uphold Mr X’s complaint. Mr X was unhappy with the response and complained to the Ombudsman.

Analysis

Initial contact

21. There was no delay regarding Mr X being contacted by the Council by telephone. This is not fault by the Council.

Poor Communication and Lack of information

22. There is no evidence the Council sent Mr X a copy of the Guide to Coroner’s Services. This is fault by the Council. As contained in paragraph 29 below, Mr X was not aware of his right to ask to see the body.
23. The Council also accepted in its final complaint response that, “it would have been better had your father’s case been dealt with more quickly and our communications with you had been more prompt. I understand that the time which passed between our original call with you ...and the subsequent contact by the actual case coroner officer...caused concern.”
24. The allocated Coroner’s officer informed Mr X that a post-mortem would need to take place. The Coroner’s officer contacted Mr X again after the post-mortem to advise him of the cause of death.
25. The Council has provided evidence to show that there was reduced capacity in respect of hospital mortuaries. On the balance of probabilities this did cause delays. The Council also says there were increased numbers of cases due to COVID-19 but has not provided statistics to show this. On the balance of probabilities, the Council did experience increased pressures due to increased numbers of deaths at the same time as a decrease in mortuary capacity.
26. The Council was unable to provide statistics showing how long it would generally take to allocate a Coroner’s Officer to a case. However, it did provide information about the length of time usually taken to release a body.
27. These statistics show the time to release Mr X’s father’s body was twice the usual period. In Mr X’s case, the time taken to allocate a Coroner’s officer to the case exceeded the average time taken over two years to release a body.
28. The Council accepted in its initial complaint response that it took too long to allocate a Coroner’s Officer to Mr X’s father’s case. There are no expected time standards for allocating a Coroner’s Officer to a case. The Council agrees it would have been better had there not been such a delay. This is service failure by the Council. Mr X experienced a lengthy delay he should not have done.

Opportunity to visit body

29. There is no evidence to show that Mr X was offered the opportunity to see the body. This is fault by the Council. Mr X suffered distress seeing his father’s body so long after he had passed away.

Delayed release of body

30. The Council provided information about the length of time usually taken to release a body. These statistics show the time to release Mr X’s father’s body was twice the usual period.
31. The Council says it would have been better if Mr X’s case had been dealt with more promptly, but also that there was no legal breach in terms of how his father’s case was handled. I agree with the Council. This is not fault by the Council.

Action by the Council

32. In its response to my enquiries. the Council has offered to arrange for the head of the Coroner’s Service to telephone and write to Mr X to apologise. I do not consider this to be an appropriate personal remedy. Mr X says a personal telephone apology is not required.

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Agreed action

33. To remedy the outstanding injustice caused by the fault I have identified, the Council has agreed to take the following action within 4 weeks of this decision:
• Apologise to Mr X in writing for the delays and the lack of opportunity to see his father’s body earlier;
• Pay Mr X £100 in respect of avoidable distress;
• Ensure that a copy of or link to the Guide to Coroner’s Services booklet is provided to every Interested Person following a death referred to the Coroner; and
• Provide guidance to staff that case record entries must record the provision of the Guide and should provide an accurate summary of matters discussed over the telephone with Interested Persons.

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Final decision

34. I have found fault by the Council, which caused injustice to Mr X. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman