Summary: Ms X complains the Council has not dealt with her mother’s death properly. The Council is at fault because it did not provide information, delayed sending the death certificate and did not respond to Ms X’s complaint clearly. The Council has agreed to apologise to Ms X, pay Ms X £175, provide information, provide guidance to staff and review its complaint responses.

The complaint

1. The complainant, who I shall refer to as Ms X, complains the Coroner’s Service has failed following the death of her mother because:
• She was given wrong information about not carrying out post mortems on people over 90;
• She was not offered the opportunity to ask for a decision review about whether or not to conduct a post mortem;
• There was a delay in providing information about what was happening to her;
• There was a delay in sending her the death certificate;
• The death certificate sent to her is not correct; and
• The handling of her complaint was poor.
2. Ms X says she has suffered distress and experienced delays in being able to administer her mum’s estate as a result, which has caused financial loss.

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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. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. 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

7. I spoke to Ms X about her complaint. I made enquiries of the Council and considered its response and the supporting documents it provided.
8. Ms 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

9. 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.
10. 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.
11. 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)

Guide to Coroner’s Services

12. 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.
13. An Interested person (IP) has 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.
14. 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.
15. Specific standards of service are set out throughout the guide.

General Register Office Deaths Handbook

16. Where a Coroner notifies a cause of death and the death has already been registered, a death certificate must not be altered and the new cause of death should be recorded in the margin with the new cause of death recorded by the Coroner.

What happened?

17. 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.
18. Ms X’s mother passed away. Her doctor provided a Medical Certificate of Cause of Death (MCCD). The Council agreed for the death to be registered and a death certificate issued without a post mortem.
19. Ms X spoke with the Council and expressed her unhappiness about a post mortem being held. The doctor contacted the Council and said they were no longer happy to issue the MCCD.
20. The Council decided to carry out a post mortem. The post mortem established a different cause of death. An updated death certificate was sent to Ms X.
21. Ms X complained to the Council. The Council provided a complaint response. Ms X complained to the Ombudsman as she was unhappy with the Council’s complaint response.

Analysis

Incorrect information

22. Ms X says she was told post mortems were not carried out on people aged over 90, the Council does not agree. There are no records of the conversations held between Ms X and the Coroner’s Officer. There is insufficient evidence to arrive at a conclusion, so I have not investigated this further.

Decision Review

23. Any decision by a Coroner whether to hold or not hold a post mortem is a quasi-judicial function and is outside the jurisdiction of the Ombudsman. However, I am able to consider the administrative functions of the Coroner’s department.
24. Ms X says she was not offered an opportunity to ask for a review of the Coroner’s initial decision not to hold a post mortem. The Council says this is not something it would do if a doctor offered a MCCD.
25. I have seen case records which show the Coroner’s Officer spoke to Ms X’s mother’s doctor, who agreed to provide a MCCD. Ms X says the doctor informed her they were told what to put on the MCCD by the Coroner’s Officer. I do not consider it probable that a GP acting professionally would allow themselves to be told what to put on an MCCD, contrary to their professional judgement.
26. On the balance of probabilities, the doctor issued the MCCD because on the information available to them it was correct to do so. If Ms X is unhappy with the doctor’s professional actions she may make a complaint about this to their professional body. This is not fault by the Council.
27. The Guide to Coroner’s Services outlines the standards of service Ms X should have expected to receive as well as outlines how to complain about or challenge a decision of the Coroner.
28. The Council did not send Ms X a copy of the Guide to Coroner’s Services. This is fault by the Council. This did not cause significant injustice to Ms X because she was able to articulate her concerns to the Coroner’s Officer and a post mortem was later undertaken when the Coroner reviewed the information available.

Delays

29. Ms X’s father’s case was completed within 28 days as stated in the Guide. There was no excessive general delay.
30. As identified above, the Guide to Coroner’s Services was not sent to Ms X.
31. The communications record provided by the Council regarding a telephone call to Ms X on 25th August is very limited and does not contain any detail about any information provide to Ms X. There is no evidence that any of the information in the Guide was provided to Ms X during this telephone call.
32. The lack of awareness of how to complain or challenge a decision of the Coroner, as contained in the Guide, led to a delay of approximately two weeks between 25th August and 8th September, when Ms X made her concerns known to the Coroner’s Officer. This is fault by the Council. The decision to undertake a post mortem may have been taken earlier if Ms X had been aware of the correct standards and the complaints process.
33. The Council accepts that there was a small delay in Ms X receiving a copy of the revised death certificate. I have seen an email showing the Council sent a second copy to Ms X by special delivery. This is fault by the Council. The sending of a second copy of the death certificate resulted in a delay of several days.
34. On the balance of probabilities, the decision making process could have been completed earlier by approximately one and a half weeks. This consequently caused a delay in Ms X resolving her mother’s housing circumstances

Incorrect Death Certificate

35. The Council says, “Due to the fact that the post-mortem took place subsequent to the original death registration, the change to the cause of death is noted via an annotation in accordance with the law and guidance on death registration. The death registration does not take place again but is annotated. It is for this reason that the death certificate will state the original cause of death (in addition to the amended cause of death).”
36. I have seen a copy of the amended and annotated death certificate. The Council has followed the General Register Office’s Death’s Handbook. This is not fault by the Council.

Complaint Handling

37. Ms X’s representations made orally to the Coroner’s Officer by telephone on 25th August were dealt with informally as per section 8.1 of the Guide.
38. There is no evidence of any further response from the Coroner’s Department to Ms X about her complaint, despite Ms X being told she would receive one.
39. There is no evidence Ms X wrote to the Coroner and sent a copy of this to the Council, as explained in the Guide. However, as Ms X had not been sent the Guide she could not know the process by which she was expected to complain.
40. The Council responded to Ms X’s later complaint raised directly to it. The complaint response did not identify at what stage of the complaints process the response was being sent, or how to progress the complaint further.
41. Neither the Coroner’s department or the Council managed Ms X’s complaint properly. Ms X did not receive a proper response.

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Agreed action

42. 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 Ms X;
• Pay Ms X £175 in respect of the costs incurred by delays in issuing a final death certificate for her mother;
• Ensure that a copy of or link to the Guide to Coroner’s Services booklet is provided to every IP following a death referred to the Coroner;
• 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 IPs;
• Provide guidance to staff to ensure its complaint procedures are followed; and
• Provide complaint response letter templates to ensure they include reference, where appropriate, to which stage of the complaints process they are issued under and how the complainant may progress their complaint if they are unhappy with the response.

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Final decision

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

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Investigator's decision on behalf of the Ombudsman