Summary: The failure to provide a recording of a coroner’s inquest as required by Government service standards is fault. There is no evidence documents used at the inquest were not copied to Ms X. A suitable remedy for the distress caused by the lack of a recording is agreed.

The complaint

1. Mrs X complains the Council has failed to provide a recording of the coroner’s inquest into her son’s death and has failed to provide details of the documents considered as part of the inquest.
2. Mrs X says this is distressing as she does not know what happened and what was considered at the inquest.

Back to top

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 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)

Back to top

How I considered this complaint

5. As part of the investigation, I have:
• considered the complaint and the documents provided by the complainant;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with the complainant;
• conducted a telephone interview with the Coroner;
• sent my draft decision to both the Council and the complainant and taken account of their comments in reaching my final decision.

Back to top

What I found

6. The coroner is an independent judicial office holder and not a local authority employee. The local authority’s statutory and administrative functions include the provision of coroner services.
7. The Ministry of Justice produces a Guide to coroner services and coroner investigations and sets out a process from when a death is reported to the coroner until the outcome of the inquest. There are service standards for each stage of the investigation. The Ombudsman can investigate complains that a coroner or the coroner’s service has breached the standards set out in the guidance.
8. Mrs X’s son, Mr Z, died in July 2018. Due to the nature of his death an inquest was held in December 2018. Mrs X chose not to attend the inquest for a variety of reasons. There had been an NHS investigation into the issues surrounding the treatment and care provided to Mr Z prior to his death which Mrs X had found emotionally and physically distressing. She knew how Mr Z died and decided she did not want to attend the inquest and listen to more details of his injuries. Mrs X was also aware that all inquests are recorded and so knew that she would be able to listen to the recording at a later date if she wanted to.
9. In May 2022, Mrs X requested a copy of the recording of the inquest. The coroner’s office informed her the recording was corrupted and so it was unable to provide a copy. It also said it had provided her with copies of all documents related to the inquest.
10. Dissatisfied with this response, Mrs X then complained to the Ombudsman.

Analysis

11. While the Council is responsible for the administration of the coroner service, the coroner is independent from it. Our jurisdiction allows us to consider the actions of the Council in regard to ensure the service standards as published by the government, are met. The Council was not able to provide a full response to my enquiries because much of the information is held by the Coroner and he indicated he must “zealously guard” his independence from the County. While he was unwilling to provide documents to the Council in response to my request to it, he was wiling to deal with me directly and as a result we had a useful telephone discussion which provided me with the information I required.
12. The service standards for coroner services state “All inquest hearings must be recorded and you have right to ask for a recording of proceedings.” It also states “If you are an interested person the coroner should have given you copies of relevant documents before the inquest.”
13. A recording was made of Mr Z’s inquest however the recording has been corrupted and is not useable. When I spoke with the Coroner he told me that there is now a different recording system in place. After the hearing the recording comes back to his office and is put onto disk and sent to the Council. An electronic back up remains with the Coroner. The system used in 2018 was different and there is no back up available. He told me that there were some other instances of problems with other hearings but the number was limited and he is confident with the system now being used.
14. The failure to be able to provide a working copy of recording of the hearing is in breach of the service standards and is fault. After speaking with the Coroner, I am satisfied a different recording system is now in place and there is no evidence to suggest an ongoing, systemic problem with the recordings. As a result of not being able to provide a copy of the recording, Mrs X is left not knowing exactly what was said at the inquest which adds to her distress.
15. Mrs X also complains that details have not been provided of exactly what documents were considered by the Coroner. In particular, there is a report which was produced by the NHS Trust that had contact with Mr Z shortly before his death. The Council was unable to provide details of the documents that were considered as part of the inquest. When I spoke to the Coroner, he told me that he always provides copies of documents considered at the inquest to the family. He said that documents had been provided to Mrs X in 2018 and that if she did not receive a copy of the particular document, then she has to assume it was not part of his consideration. He stated that his role is not concerned with why someone died but about the where, when and how.
16. There is nothing to suggest Mrs X was not provided with the relevant documents in 2018. While I understand and respect her decision not to attend the inquest, it is now four years since it was held which makes it difficult to be certain about exactly what documents were provided to her. My interview with the Coroner persuaded me the systems in place to provide documents are appropriate. It is a matter of the professional judgement of the Coroner to decide what information is relevant and what should be considered to enable him to make his decision. While Mrs X may have wanted a particular document to be considered, that would not be a matter she could influence. I am not persuaded there has been any breach of the service standards in regard to the documents.

Back to top

Agreed action

17. To remedy the injustice caused to Mrs X as a result of the fault identified in this case, the Council will, within one month of my final decision, take the following action:
• Provide a written apology to Mrs X;
• Make a symbolic payment of £250 to recognise the distress caused;
• Review the inquest recording system to ensure it is fit for purpose and that suitable storage and back up systems are in place.
18. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

19. I have completed my investigation with a finding of fault for the reasons explained in this statement. The Council has agreed to implement the actions I have recommended. These appropriately remedy any injustice caused by fault.

Back to top

Investigator's decision on behalf of the Ombudsman