Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.

The complaint

1. I refer to the complainant here as Mr X. Mr X says the Coroner failed to keep him informed of the post-mortem process, specifically:
• The Coroner failed to inform him of when and where his child’s post-mortem was being held;
• The Coroner failed to contact him on the day of the post-mortem to inform him of the outcome of the post-mortem; and
• The case officer did not explain and share information with him so he could consider his options in accordance with the Human Tissues Act.
2. Mr X says the failings left his family devastated and caused them immeasurable distress. Mr X says the organisation should be held to account and appropriate compensation should be made to him for the distress caused.

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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. 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

5. I examined the complaint and background information provided by Mr X and the Council. I sent a draft decision statement to Mr X and the Council and considered the comments of both parties in reply to the statement.

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What I found

6. The Coroner’s office initially discussed the post-mortem process with Mr X and told him a post-mortem was required to find out the cause of death of his child. But then he did not hear anything further from the Coroner’s office for two weeks. Mr X then contacted the Coroner’s office only to find out the post-mortem had already been completed.
7. The Coroner’s office noted the reason for the failings in this case was that the case officer had arranged the post-mortem independently as it was to being held outside the county of Surrey. The case officer was then away from the office for the crucial period when the post-mortem took place. This affected communication with Mr X.
8. The Coroner’s office reviewed this practice and decided that any post-mortems arranged outside the county should be managed through its business team in the same way as post-mortems managed within the county.
9. Where we find fault by a local authority we must go on to consider the injustice caused and a possible remedy for the injustice. In this case, It was accepted by both the Coroner’s office and the Council that Mr X was not kept informed of proceedings as he should have been. Both services apologised to Mr X.
10. I acknowledge Mr X was distressed by the failings in this case. The distress was exacerbated by the grief he felt at the loss of his child. I recommended the Council make a payment of £200 to Mr X to reflect the distress he was caused by its failings. The Council agreed to do so.
11. I note Mr X wants the Coroner’s office to be held to account. The practice improvements proposed and already put in place by the Coroner’s office provide the outcome Mr X wants.

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Final decision

12. There was fault by the Council. The complaint was closed because the Council agreed to remedy the injustice caused to Mr X.

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Investigator's decision on behalf of the Ombudsman