Summary: Mr X complains the Coroner’s office failed to tell him his sister’s brain had been removed at a post-mortem. This caused him and his family distress and financial loss. We find fault with the Council. We have made some recommendations to remedy the injustice caused.

The complaint

1. Mr X complains the Coroner’s office failed to tell him his sister’s brain had been removed at a post-mortem. This meant the family cremated his sister without her brain. Mr X says this caused emotional distress at knowing his sister was not whole during the original funeral. He says this also caused financial loss as the family had to travel again to scatter the ashes for a second time.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I spoke with Mr X and considered the information he provided.
5. I considered the information provided by the Council.
6. I sent a draft decision to Mr X and the Council for their comments.

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What I found

Ombudsman’s guidance on remedies

7. Our key principle is the remedy should, as far as possible, put the complainant back in the position he or she would have been in but for the fault we have identified. If this is not possible, financial redress may be the only available remedy.
8. We can consider whether the complainant has incurred avoidable expenses due to the fault.
9. A remedy payment for distress is often a moderate sum of between £100 and £300. In cases where the distress was severe or prolonged, up to £1,000 may be justified.

What happened

10. The Council is the funding authority for the Coroner’s office. Therefore, while we refer to the actions of the Coroner’s office in this decision, the Council has responsibility for the actions taken.
11. In July 2021, the Coroner’s office received a cause of death form from the pathologist for Mr X’s sister, Ms Y. This form detailed the pathologist had removed the brain from Ms Y’s body as part of histology samples for neuropathology examination.
12. In the beginning of August 2021, Ms Y’s body was cremated.
13. In mid-August 2021, the Coroner’s office became aware Ms Y’s brain had removed from her body. The office contacted Mr X and his family immediately to discuss the error.
14. During a meeting, Mr X confirmed to the Coroner’s office the family wanted Ms Y’s brain to be cremated so they could reunite the ashes with the existing ashes. The Coroner’s office agreed to make all the arrangements for this.
15. In December 2021, the hospital released Ms Y’s brain. The Coroner’s office arranged and paid for the cremation. Mr X said he had to travel again to scatter the ashes to reunite them with the other ashes. Mr X said this was an extra cost to him and his mother.
16. In response to Mr X’s complaint, the Council, accepted it was at fault and noted it had arranged to cremate the brain. The Council also apologised and offered a financial payment of £200 to recognise the distress caused to Mr X and his family.
17. In response to our enquiries, the Coroner’s office confirmed the error was due to a member of staff not identifying from the cause of death form the pathologist had removed the brain. The Coroner’s office also confirmed it had completed the following actions as part of its learning from the complaint:
• It had set up a new case management system to manage referrals to the Coroner. Within this system, where whole organs are removed, it was now documented and tasked within the new system for staff to have a discussion with the family to allow them to consider their options on how to proceed.
• It had completed one to one coaching with all staff, including the staff member who made the mistake. This was to highlight the process staff should follow where organs are removed. As part of this coaching, the Council reminded staff to be vigilant in reading instructions on all forms, including cause of death forms.

Analysis

18. It is clear there was fault as the Coroner’s office failed to tell Mr X and his family that Ms Y’s brain was not with her body. This meant they cremated Ms Y’s body without her brain. We recognise this would have been extremely distressing for Mr X and his family.
19. Mr X told us he wanted compensation for the distress caused by the fault. He also told us he had to pay for the extra travelling expenses of around £100 to travel to scatter the ashes for a second time.
20. The Ombudsman will make a financial remedy when there is no other way to put the complainant back in the position they would have been if not for the fault. This financial remedy is a token payment to recognise the distress caused and is not considered compensation. We do not offer or make recommendations for compensation in the same way a court might.
21. Our guidance on remedies notes that where a fault has caused distress, the payment is often a moderate sum of between £100 and £300. In cases where the distress was severe or prolonged, up to £1000 may be justified.
22. In this case, we consider the Council’s offer of £200 to be lower than what we would recommend. This is especially considering the nature of the fault and the impact this would have had on Mr X and his family during an already difficult time.
23. In reaching our financial figure, we have considered the action taken by the Coroner’s office once it identified the fault:
• It told Mr X and his family of the mistake without delay once it became aware of it.
• It arranged to cremate the brain once it was ready to be released.
• It offered Mr X a financial payment in recognition of the distress caused
• It accepted the fault immediately when Mr X raised his complaint.
• It completed learning and improved its process to prevent the mistake from happening again.

Therefore, the prompt action taken ensured Mr X’s distress was not increased or prolonged.

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Recommended actions

24. To remedy the injustice caused by the fault, the Council has agreed to complete the following:
• Pay Mr X £500 to recognise the distress caused to him and his family by the fault.
• Reimburse Mr X for the travel costs incurred to scatter the ashes for a second time. Ordinarily we would ask complainants to provide evidence of costs incurred. However, given the time that has since passed and the sensitivity of the circumstances, we do not consider it appropriate to ask Mr X to do so now. Mr X has estimated the travel expenses for him and his mother to be around £100. We are satisfied this is a reasonable amount in the circumstances.

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Final decision

25. I find fault with the Council for failing to tell Mr X that his sister’s brain had been removed from her body. The Council has accepted our recommendations. Therefore, we have completed our investigation.

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Investigator's decision on behalf of the Ombudsman