Summary: Mrs X complains about incorrect timescales given by the Coroner’s Office that led to her incurring avoidable travel expenses. Mrs X also complains about delays in responding to her complaint. We have concluded our investigation having made a finding of fault. Although we found the Council provided Mrs X with timescales that were accurate at the time, there were significant delays in responding to her complaint. However, the Council has apologised to Mrs X, and we are satisfied this is a proportionate response, so there is no further action required.

The complaint

1. Mrs X complains about incorrect information given by the Coroner’s Office. Mrs X says she has incurred avoidable travel expenses and was unable to see her brother after she was given the wrong dates. Mrs X also complains about the time taken to respond to communications she had sent. Mrs X would like to be reimbursed for her travel expenses and an award made for distress caused by the information she was given.

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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. 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)
4. 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.
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 liaised with Mrs X and considered the information she provided. I also considered the information the Council provided in response to my enquiries. I considered any comments Mrs X and the Council submitted in response to my draft decision.

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What I found

Law, guidance and policies

7. 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.
8. 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.
9. 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

10. 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
11. 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.
12. 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.
13. Specific standards of service are set out throughout the guide.

The Council’s complaints policy

14. The Council says if a complainant is dissatisfied with the outcome of their complaint response at stage one, they may ask for your complaint to be reconsidered.
15. A request must be made within 20 working days of the date of the stage 1 complaint response and a more senior officer will then investigate the complaint, review the stage one response and provide a new response within 20 working days.
16. If the complaint is complex and takes longer to investigate, the Council says it will keep the complainant informed.

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What happened

17. I have included a summary of some of the key events in this complaint. It is not intended to be a comprehensive account of everything that took place.
18. Mrs X’s brother, Y, passed away on 8 April 2022. Mrs X contacted the Coroner’s Office on 12 April 2022. The Coroner’s office confirmed to Mrs X that Y was in their care, and that a post-mortem had been requested at Hospital X.
19. The Coroner’s Office informed Mrs X that the post-mortem would not be completed until the following week because of the easter bank holidays. Mrs X informed the Coroner’s Office that she would return to the UK that week.
20. Mrs X returned to the UK on 14 April 2022. Some days later, Mrs X called the Coroner’s Office, and says she was informed that Y’s post-mortem was taking place.
21. Mrs X continued to call the Coroner’s Office for an update, and says she was informed the report had not yet been completed but was not told that Y’s post-mortem had not yet taken place.
22. On 5 May 2022, Mrs X received an email informing her that no post-mortems were taking place until the week commencing 9 May 2022.
23. On 9 May 2022, Y’s post-mortem was completed. On 10 May 2022, the Coroner’s Office spoke with Mrs X to inform her of the results.
24. On 6 June 2022, Mrs X raised a complaint. The Council provided a complaint response on 21 June 2022. Later in June, Mrs X expressed dissatisfaction with the response to her complaint.
25. In July 2022, the Council wrote to Mrs X to inform her it required more time to investigate her complaint at Stage 2. Mrs X chased an update in August, and at the end of August, the Council issued its Stage 2 complaint response. Mrs complained to the Ombudsman as she was unhappy with the Council’s Stage 2 complaint response.

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Analysis

Did the Coroner’s Office provide Mrs X with an incorrect post-mortem date?

26. When the Coroner’s Office informed Mrs X that the post-mortem for Y would take place in the week commencing 18 April 2022, that information was accurate at the time. I have not seen any evidence that it was aware of any delays from Hospital X when it informed Mrs X of the timescales.
27. The Coroner’s Office became aware of delays when it was informed by Hospital X on 21 April 2022, after Mrs X had returned to the UK, that it had been unable to provide a post-mortem service so far that week. Hospital X informed the Coroner’s Office and that it would be unable to do so unless it were able to find a Locum Mortuary Technician.
28. I therefore have not made a finding of fault. The information provided to Mrs X was correct at the time, and any delays in completing Y’s post-mortem were outside the control of the Council. The Council were not informed of delays in the process until after Mrs X returned to the UK, so there was not an opportunity for it to inform Mrs X so she could delay her travel.

Did the Coroner’s Office provide Mrs X with incorrect information?

29. Mrs X says she was informed by the Coroner’s Office that Y’s post-mortem was taking place. I asked the Council to provide call-notes, but these were insufficient in determining what was discussed in the call.
30. The Council says it is unlikely the Coroner’s Office would have informed Mrs X that the post-mortem was taking place, or had been completed as it would not receive confirmation of this until it received the post-mortem report. The Council says the Coroner’s Office does not receive any notification that a post-mortem is either taking place or has been completed.
31. Whilst I acknowledge this would have been a distressing time for Mrs X, on balance I conclude that the Coroner’s Office is unlikely to have provided incorrect information to Mrs X regarding Y’s post-mortem.

Complaint handling

32. The Council says it will provide a stage 2 complaint response within 20 working days. The Council wrote to Mrs X in July 2022, to inform her it required more time to investigate her complaint. Mrs X did not receive this correspondence from the Council. The Council acknowledges that this correspondence did not deliver to Mrs X due to a technical issue.
33. The Council did not provide a stage 2 complaint response to Mrs X until late August 2022, 45 working days after Mrs X raised a stage 2 complaint and 25 working days late. This is fault.
34. Although I have made a finding of fault, I do not consider there is scope for an additional remedy or scope to suggest service improvement. The Council apologised to Mrs X for the delay, and it has since put additional administrative checks in place to ensure similar technical issues are identified.

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Final decision

35. I have concluded my investigation having made a finding of fault. Although I found the Council provided Mrs X with timescales that were accurate at the time, there were significant delays in responding to Mrs X’s complaint. However, the Council have apologised to Mrs X, and I am satisfied this is a proportionate response so there is no further action required.

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Investigator's decision on behalf of the Ombudsman