Summary: Ms X complained about the way the coroner’s office handled the investigation of the death of her son. Most of the complaint is not within our jurisdiction but there was fault by the Council in how it responded to the complaint.

The complaint

1. I refer to the complainant as Ms X. She is represented in bringing this complaint by a solicitor, Ms D. She complains about the handling by the coroner’s office of the investigation into the death of Ms X’s son, Mr Z. The main elements of the complaint are:
• Failure to inform the family that they could be represented at the postmortem examination;
• Failure to correspond with the family, or their representatives, in accordance with the relevant guidance;
• Delay in providing a copy of the postmortem report;
• Delay and failure to provide the supporting information to the postmortem report;
• Failure by the Council to respond to the complaint.

Ms X has been caused distress as a result of the alleged failings.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’ by a body within our jurisdiction. (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 considered the complaint and documents provided by Ms D and spoke to her I asked the Council to comment on the complaint and provide information. Ms D and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Summary of key guidance and the relevant legal context

5. A coroner is an independent judicial office holder appointed by a council. They investigate deaths reported to them, including those where cause of death is unknown. They direct the work of coroners’ officers who can be employees of the council, police officers or civilians employed by the police. Section 24 of the Coroners and Justices Act (2009) requires councils to fund coroner’s offices.
6. The Ministry of Justice (MoJ) publishes a guide to coroner’s services which sets out service standards and offers advice on how to complain about a coroner’s office. The guidance was updated in 2020. It states that if someone has a complaint about the way a coroner or their staff handled an investigation they should first write to the coroner and send a copy of their letter to the relevant council. Where the coroner’s officers is employed by the police the complainant should write to the police service. The guide states that someone who is dissatisfied with a coroner service may also complain to the council. And if they are unhappy with the council response then they can complain to us about how the council dealt with them.

What happened

7. Ms X’s son died in May 2022 and the death was referred to the coroner. The complaint concerns the conduct and action of the coroner’s office staff.
8. In March 2023 the solicitors acting for Ms X complained to the Council about the coroner’s office. The Council responded. It said it could not consider the complaint as it fell outside the scope of the complaints process as there were other more suitable processes for dealing with them. It referred the solicitors to the coroner’s office. Or to us if they remained dissatisfied.
9. The solicitors responded immediately saying the Council’s position was wrong. They referred to the Ministry of Justice guide saying that as the complaint was about the standard of service provided by the coroner’s office it clearly fell to be considered by the Council. But they would do as the Council suggested and complain to us.

Jurisdiction

10. A coroner’s duties and functions under the 2009 Act remain the coroner’s despite being appointed and paid by the council and coroner’s officers being provided by the council and/or the police. When undertaking tasks on behalf of a coroner as part of the coroner’s statutory functions relating to coronial investigations, coroner’s officers are exercising the coroner’s functions, not those of the council.
11. We can consider complaints about alleged or apparent maladministration in connection with the exercise of a council’s administrative functions. The matters that are the subject of this complaint concern the actions of the officers acting on behalf of the coroner in carrying at the coroner’s statutory functions. The actions were not administrative functions of the Council and are not, therefore, within our jurisdiction.
12. The MoJ guide states that a complaint about the coroner’s service can be made to the council. If the complainant remains dissatisfied they can complain to the Council. If they are still dissatisfied then they can complain to us about how the Council dealt with them.
13. I do not consider the Council’s response to the complaint was adequate. It said there were other more suitable processes for dealing with the complaints. But it did not explain what those processes were, or respond when the solicitors replied explaining why they considered the Council was wrong. The Council should have explained the officers were employed by the police service and what the next steps were. The failure to do so is fault. Had it done so then the solicitors could have decided whether they wished to raise the complaint with the police service.

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Agreed action

14. The Council should apologise, in accordance with our guidance on making an effective apology, for the failing in how it responded to the complaint.
15. The Council should review the information it provides in response to complaints that are not covered by its complaints procedure to ensure it provides an adequate and accurate response.
16. It should provide us with evidence it has complied with the above actions. For the first point within one month and the second within two months.

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Final decision

17. I find there was fault by the Council.

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Investigator's decision on behalf of the Ombudsman