The Ombudsman's final decision
Summary: Mr X says the Coroner failed to keep him informed of the post-mortem process involving his deceased child. The Council accepted fault and apologised to Mr X. The Council agreed to a financial remedy to reflect the distress caused to Mr X.
The complaint
I refer to the complainant here as Mr X. Mr X says the Coroner failed to keep him informed of the post-mortem process, specifically: The Coroner failed to inform him of when and where his child’s post-mortem was being held; The Coroner failed to contact him on the day of the post-mortem to inform him of the outcome of the post-mortem; and The case officer did not explain and share information with him so he could consider his options in accordance with the Human Tissues Act.
Mr X says the failings left his family devastated and caused them immeasurable distress. Mr X says the organisation should be held to account and appropriate compensation should be made to him for the distress caused.
The Ombudsman’s role and powers
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) If we are satisfied with a council’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)
How I considered this complaint
I examined the complaint and background information provided by Mr X and the Council. I sent a draft decision statement to Mr X and the Council and considered the comments of both parties in reply to the statement.
What I found
The Coroner’s office initially discussed the post-mortem process with Mr X and told him a post-mortem was required to find out the cause of death of his child. But then he did not hear anything further from the Coroner’s office for two weeks. Mr X then contacted the Coroner’s office only to find out the post-mortem had already been completed.
The Coroner’s office noted the reason for the failings in this case was that the case officer had arranged the post-mortem independently as it was to being held outside the county of Surrey. The case officer was then away from the office for the crucial period when the post-mortem took place. This affected communication with Mr X.
The Coroner’s office reviewed this practice and decided that any post-mortems arranged outside the county should be managed through its business team in the same way as post-mortems managed within the county.
Where we find fault by a local authority we must go on to consider the injustice caused and a possible remedy for the injustice. In this case, It was accepted by both the Coroner’s office and the Council that Mr X was not kept informed of proceedings as he should have been. Both services apologised to Mr X.
I acknowledge Mr X was distressed by the failings in this case. The distress was exacerbated by the grief he felt at the loss of his child. I recommended the Council make a payment of £200 to Mr X to reflect the distress he was caused by its failings. The Council agreed to do so.
I note Mr X wants the Coroner’s office to be held to account. The practice improvements proposed and already put in place by the Coroner’s office provide the outcome Mr X wants.
Final decision
There was fault by the Council. The complaint was closed because the Council agreed to remedy the injustice caused to Mr X.
Investigator's decision on behalf of the Ombudsman