Coroner family information gaps

The Governor

The Governor should ensure that all decisions taken are recorded in the Family Liaison Officer’s log.

Altcourse (2020)

Delays in scheduling Coroner inquests have caused anxiety for staff attending as witnesses and families awaiting closure.

Ministry of Justice

Oakwood (2022)

Can the Minister ask the Chief Coroner to issue guidance about the importance of notifying the IMB of inquests concerning prisoners (para 4.2) as referred to in the IMB reference book guidance in relation to deaths in custody?

Ministry of Justice

Lowdham Grange (2022)

In its 2020-2021 report, the Board requested priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives. No inquests into deaths in custody at HMP Lowdham Grange have been held in the reporting period and this means that some families have been waiting …

Ministry of Justice

Lowdham Grange (2023)

The Board continues to request that priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives.

Ministry of Justice

Hewell (2020)

Please conclude the report into the death on 14 June 2018, so that an inquest may be carried out.

Other

Lowdham Grange (2021)

Ensure that priority is given to holding Coroner’s inquests for deaths in custody to enable prisoners’ families to understand more of the circumstances of the deaths of their relatives.

Ministry of Justice

Hindley (2022)

The Board queries the significant delays in holding inquests and the resultant distress to the families and staff involved – one inquest has been outstanding since 2019. Would the Minister examine what can be done to reduce this unacceptable delay?

Ministry of Justice

Stoke Heath (2024)

When will the Governor improve the system to inform the IMB about deaths in custody, so that we know as soon as possible?

Governor / Director

Garth (2020)

It would be a benefit to all if the process [for investigating deaths in custody] could be speeded up.

Ministry of Justice

Littlehey (2021)

With the high number of deaths in custody the Board asks whether the Governor will be focussing on the learning points from those that have occurred and, whether she will be addressing the number of trained family liaison officers (FLOs).

Governor / Director

Thameside (2025)

The prison should review information for prisoners’ families, both on the website and in the visitors’ centre, to ensure it is updated, clear, and consistently applied.

Governor / Director

Hollesley Bay (2024)

The Board suggests that there is a need to review the handling of prisoners’ post, in particular where healthcare appointments are concerned.

Governor / Director

Scotland and Northern Ireland short-term holding facilities (STHF) (2025)

Access to phones in holding rooms is often poor. Information provision can also be weak. For example, some people we spoke to did not recall being informed of their right to legal advice. What steps are being taken to standardise provision in line with best practice, and to properly enforce non-compliance?

Other

Maidstone (2023)

To work with the Home Office to require that prisoners sign official documentation either in their own language or in a language they understand. Many prisoners need help with translation that they are not receiving.

Home Office

Stoke Heath (2024)

The Governor should improve the system to inform the IMB about deaths in custody, so that we know as soon as possible.

Governor / Director

An independent review of the Independent Investigations for Mental Health … — Rec 8

It is recommended that the IIGC should develop measures to demonstrate the impact and outcomes of the Independent Investigation process, with particular regard to; learning, service improvement, policy development and the experience of all affected families and carers.

north_east_yorkshire

— LP 15

This is the gold standard approach to family involvement. Prisons vary in the quality of family involvement and HMP Altcourse is sadly not unusual in how it approaches this important area. There should be improved across all prisons.

HMP Altcourse and HMPPS Accepted

— LP 14

With the prisoner’s consent, a prisoner’s relatives should be contacted to gather information as a collateral history is extremely useful. They should also be given information, again with consent, about the prisoner’s condition. They should be included in care-planning meetings and the ACCT process where appropriate.

HMP Altcourse and HMPPS Accepted

— LP 13

There should be a clear procedure for relatives, carers and friends to contact the prison to pass on information, express concerns or inquire about their loved-one’s wellbeing. Some prisons have a telephone hotline service, with a guarantee that the appropriate department will respond. Not only should there be a point …

HMP Altcourse and HMPPS Accepted

— LP 4

We recommend that stronger efforts are made to assemble and substantiate basic information about prisoners’ next of kin and family situation, particularly where young offenders are concerned.

HMPPS Accepted

— LP 10

Doncaster Prison should develop a policy for relative/next of kin liaison in circumstances other than deaths in custody, including life-threatening situations.

The Governor Accepted

— LP 2

HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.

HMP Featherstone Accepted

— LP 9

We recommend that in conjunction with PECS, GEOAmey develops a policy for family liaison, with a senior member of staff designated as family liaison lead and with training for that role.

PECS and GEOAmey Accepted

— LP 8

We recommend that in conjunction with PECS, GEOAmey puts in place a procedure for a senior manager to be notified whenever a serious incident of illness or other harm occurs. The designated senior manager should take immediate responsibility for ensuring that families are notified at the earliest opportunity, facilitating access …

PECS and GEOAmey Accepted

— LP 10

Where possible, families should be encouraged to input into the ACCT process.

HMP Altcourse and HMPPS Accepted

— LP 10

We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in …

GEOAmey and HMPPS Accepted

— LP 2

HMP Norwich should ensure that there is an awareness of the contents of property returned to prisoners next of kin, and that such returns are handled sensitively

HMP Norwich

— LP 20

The prison must ensure that when a prisoner is on a bed watch in hospital and in a poor state of health, following an incident of life threatening self-harm, they achieve a balanced risk assessment of the need to have prison officers present to protect the public and the prisoner’s …

HMP Altcourse Accepted

— LP 5

We recommend that particular consideration is given to ensuring that CAREMAPs include reference to specific arrangements for engaging with families unless a reason is given elsewhere in the document why this is inappropriate.

HMPPS Accepted

— LP 4

We recommend that Swansea Prison considers the selection, appointment and training of a Family Liaison Officer as a member of the Safer Custody Team, to promote engagement with families as part of the ACCT scheme, to monitor the operation of this in practice, and to report periodically to the safer …

HMPPS Accepted

— LP G

More resources should be used to establish next of kin swiftly, especially in foreign national cases. Enquiries could be made through Police intelligence officers, the UK Border Agency and any church or community groups with whom a prisoner had been associated.

HMPPS Accepted

P-001291 — West Hertfordshire Hospitals NHS Trust

Ms A complained that West Hertfordshire Hospitals NHS Trust would not provide her with details about the cause of her partner's death as she is not his next of kin.

NHS in England Feb 2022

P-002593 — Croydon Health Services NHS Trust

Miss A complains the Trust did not tell her or her mother that her mother's cancer had spread and she had a short time to live. She also complains about the end of life care.

NHS in England Partly Upheld May 2024

P-002646 — Manchester University NHS Foundation Trust

Mrs G complains the Trust did not contact her when her father had a fall and another time it left him lying on a bed pan for over two hours. She complains it did not tell her when her father died but contacted someone else and gave them her father's …

NHS in England Upheld May 2024

P-002832 — United Lincolnshire Hospitals NHS Trust

Ms O complains the Trust communicated poorly with her family about her brother’s care, that it failed to provide a diet that was appropriate for his swallowing difficulties, it delayed putting a plan in place for her brother’s rehabilitation and it failed to support the family and effectively co-ordinate her …

NHS in England Upheld Jul 2024

P-004262 — University Hospitals of Liverpool Group

Daughter complains that poor communication regarding her father's deterioration meant she lost the chance to spend valuable time with him prior to his death.

NHS in England Upheld Nov 2025

P-002047 — Northumbria Healthcare NHS Foundation Trust

Mrs O complains the Trust did not do the autopsy on her father’s body correctly because details on the report were wrong.

NHS in England Jun 2023

P-002052 — County Durham and Darlington NHS Foundation Trust

Mr I complains the Trust delayed his mother's hip surgery and this led to her unexpected death. He complains the family could not visit and were not with her when the risks of surgery were explained to her. He also complains he found out about his mother's death by text …

NHS in England Jun 2023

P-002455 — A practice in the Lancashire area

Mrs H complains the Practice did not complete a referral to a specialist quickly enough for her father and did not complete a home visit the day he died. She also complains it gave incorrect information to the coroner.

NHS in England Feb 2024

P-002493 — Leeds Teaching Hospitals NHS Trust

Mrs M complains about the Trust’s communication with her about the use of midazolam and her father’s deterioration. She says this meant she was denied opportunity to be with her father when he died.

NHS in England Upheld Mar 2024

P-002824 — University Hospitals Birmingham NHS Foundation Trust

Mrs G complained about the care the Trust provided to her mother during her final admission. She was also unhappy about its communication regarding how close she was to the end of her life.

NHS in England Jul 2024

P-002782 — Barts Health NHS Trust

Miss F complains about how the Trust managed her mother’s deterioration and communicated with her about this.S

NHS in England Partly Upheld Jul 2024

P-002791 — North Middlesex University Hospital NHS Trust

Mr A complains the Trust did not communicate with the family about the plan for his mother’s surgery or explain how serious the situation was. He also complains there were delays in his mother’s care and arranging appropriate investigations after her stroke and about how she was monitored while in …

NHS in England Jul 2024

P-003069 — The Princess Alexandra Hospital NHS Trust

Mrs W complains about the care her father received in hospital, poor communication before he died and the completion of his death certificate.

NHS in England Oct 2024

P-003162 — Tameside and Glossop Integrated Care NHS Foundation Trust

Mrs N complains Tameside and Glossop Integrated Care NHS Foundation Trust have not taken enough action following a coroner’s prevention of future deaths report.

NHS in England Nov 2024

P-003479 — Isle of Wight NHS Trust

Mrs F complains the Isle of Wight Trust did not communicate her husband’s diagnosis and transferred him to Portsmouth Hospitals Trust before she could see him. She complains Portsmouth Hospitals Trust failed to provide appropriate care on his admission and did not communicate his death to her in a timely …

NHS in England Apr 2025

P-003567 — Barking, Havering and Redbridge University Hospitals NHS Trust

Mrs X complains about issues with communication following her brother’s death. She says she was told the bereavement team would contact her, so she could see her brother before he was taken to the mortuary but, this was the wrong advice.

NHS in England May 2025

P-003645 — Barnsley Hospital NHS Foundation Trust

Ms G complained about the care her mother received as an inpatient and the Trust’s communication with her family at the end of her life.

NHS in England Jul 2025

P-003667 — South Tyneside and Sunderland NHS Foundation Trust

Mrs O complains that between 2017 and 2023 the Trust failed to inform her husband that his prostate cancer diagnosis was life-limiting and untreatable.

NHS in England Jul 2025

P-001351 — North Middlesex University Hospital NHS Trust

Miss A complained about the level of care the Trust provided to her aunt (Mrs F) during December 2018. She also complains about its poor communication with the family regarding Mrs F's diagnosis and prognosis.

NHS in England Partly Upheld Mar 2022

P-001461 — County Durham and Darlington NHS Foundation Trust

Mrs A complains that the Trust provided conflicting information regarding her mother, Mrs O's, death. She complains when information about her mother’s death was provided via Data Subject Access Request (SAR), parts of the reports were redacted or withheld and not fully disclosed.

NHS in England Jul 2022

P-001464 — Ashford and St Peter's Hospitals NHS Foundation Trust

Miss U complains about the poor communication and misinformation she received from the Trust while her father, Mr U, was an inpatient and receiving palliative care.

NHS in England Jul 2022

P-001830 — Gateshead Health NHS Foundation Trust

Mrs O complains the Trust did not communicate the severity of her mother's condition, that it did not explain what it was doing or update the family.

NHS in England Nov 2022

P-001653 — University Hospitals Coventry and Warwickshire NHS Trust

Mr P complains the Trust did not tell him or his family about his daughter's skin damage when she was discharged. He also complains it failed to refer his daughter to the district nursing team for ongoing care and treatment.

NHS in England Partly Upheld Dec 2022

P-002636 — Hampshire Hospitals NHS Foundation Trust

Mrs S complains the Trust did not tell her about her minor scoliosis or Bertolotti's syndrome diagnosis, it did not treat her ankle pain, it gave her mixed information about her condition and potentially incorrect medication.

NHS in England May 2024

P-002818 — Mid and South Essex NHS Foundation Trust

Miss A complains about the care, communication and treatment her grandfather had from the Trust from December 2023 to January 2024.

NHS in England Jul 2024

P-003234 — Tameside and Glossop Integrated Care NHS Foundation Trust

Miss G complains the Trust did not act promptly enough following her partner’s diagnosis in 2017 of Interstitial Lung Disease. She is also concerned the Trust did not notify her partner’s brothers about possible risks to them.

NHS in England Partly Upheld Dec 2024

P-003456 — Hertfordshire Community NHS Trust

Mrs J complains about the care and treatment her brother, Mr P, received during admissions at East and North Hertfordshire NHS Trust and Hertfordshire Community NHS Trust between 21 December 2019 and 5 January 2020. She complains the failings the safeguarding team and coroner identified may have contributed to or …

NHS in England Upheld Mar 2025

P-003394 — London North West University Healthcare NHS Trust

Ms E complains the Trust did not contact her when her father died and she arrived to visit him not knowing he had died. She also complains about aspects of her father’s care in his final days.

NHS in England Mar 2025

P-003437 — University Hospitals of Derby and Burton NHS Foundation …

Mr Z complains the Trust did not inform his wife about the development and prognosis of her cancer meaning there was a lost opportunity for her to change treatment.

NHS in England Upheld Mar 2025

P-004165 — Barking, Havering and Redbridge University Hospitals NHS Trust

Mr W complains that his aunt, Mrs O, was incorrectly put onto end-of-life care without any consultation with her family, and that she received a substandard level of care. Mr W also complains about the clinical teams level of communication with him, and about the way his complaint was handled.

NHS in England Oct 2025

P-004144 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Mr H is concerned about the care his father received from the Trust, specifically that CT scan findings were not acted upon and that the end-of-life care process was poorly communicated.

NHS in England Oct 2025

P-004132 — Oxford University Hospitals NHS Foundation Trust

Dr A complains about aspects of care and treatment her mother, Mrs A, received when she choked on her food at the Trust. She is also concerned about how the Trust investigated the incident and completed the death certificate.

NHS in England Upheld Oct 2025

P-004256 — Epsom and St Helier University Hospitals NHS Trust

Mrs K complains about the care provided to her mother. She says the Trust missed an opportunity to diagnose cancer and the standard of communication was inadequate.

NHS in England Partly Upheld Nov 2025

P-004259 — The Royal Wolverhampton NHS Trust

Miss N complains the Trust failed to tell her mother of a cancer diagnosis, and provide adequate pain relief.

NHS in England Upheld Nov 2025

P-004299 — Surrey and Sussex Healthcare NHS Trust

Mr C says signs of cancer were missed on his partner Ms M's CT scans throughout 2022. When cancer was found on scans later in the year, there was a 3 month delay in informing Ms M and starting treatment for cancer.

NHS in England Partly Upheld Nov 2025

P-004304 — Royal Devon University Healthcare NHS Foundation Trust

Mrs K complains about the Trust's management of her husband's pain relief and swallow, and its delay in diagnosing and communicating that his cancer had spread to his bones.

NHS in England Partly Upheld Nov 2025

P-004464 — University Hospitals Birmingham NHS Foundation Trust

Mrs O complains about aspects of care provided to her father, Mr E, by the Trust during his admission from April 2024. She complains about the lack of communication between the Trust and Mr E's family in relation to care/condition of Mr E, the status of ‘do not attempt cardiopulmonary …

NHS in England Dec 2025

P-002794 — Crown Prosecution Service

Miss C complains the CPS prosecuting barrister failed to read her Victim Personal Statement to the court before sentencing.

UK Government Jul 2024

P-001764 — Northampton General Hospital NHS Trust

Ms A complains the Trust should not have allowed her father to go to the toilet unaccompanied and without his oxygen. She also complains it made decisions without discussing treatment with her first and it did not properly communicate the circumstances of her father’s death with her.

NHS in England Jan 2023

P-001727 — Frimley Health NHS Foundation Trust

Mrs L complains about the Trust's treatment and care of her husband. She also complains about its lack of advice, communication and how it handled her complaint.

NHS in England Upheld Jan 2023

P-002400 — Sheffield Teaching Hospitals NHS Foundation Trust

Ms J complains that when her father showed signs of a bowel obstruction, the Trust failed to control his pain. She also says the Trust did not tell her about her father’s deterioration and she and her mother were not given the opportunity to see him before he died.

NHS in England Not Upheld Jan 2024

P-002415 — Sheffield Teaching Hospitals NHS Foundation Trust

Mrs F complains the Trust did not make her or her husband aware of the risk of liver cancer, while her husband was having treatment for eye cancer between June 2020 and November 2021.

NHS in England Jan 2024

P-003111 — A practice in the Thurrock area

Mr A complains the Practice failed to refer his father for a two week wait cancer referral in early 2023 after he developed new symptoms. Mr A says that after his father’s diagnosis and admission to hospital, the Trust did not to manage his care correctly or communicate how serious …

NHS in England Nov 2024

P-003374 — James Paget University Hospitals NHS Foundation Trust

Mrs A complains about a doctor’s communication during her husband’s admission in June 2023. She says they did not communicate effectively and discuss the treatment options with her family during her husband’s final hours.

NHS in England Feb 2025

P-003447 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Mr N complains about the Trust’s management of his mother’s care in February and March 2021. He says it denied him access to meetings and made important decisions about his mother’s care without his knowledge. He also complains about the complaint handling.

NHS in England Mar 2025

P-003536 — University Hospitals of Liverpool Group

Mrs R complains about the Trust’s treatment of her late sister. She says it failed to detect liver cancer, to provide an urgent and clear care plan, it delayed scans and did not explain the risks of taking medication. She also complains about the record keeping and communication with the …

NHS in England Partly Upheld Mar 2025

P-003477 — A practice in the Wiltshire area

Mr O complains the Trust failed to identify multiple fractures and did not give him antibiotics to prevent an infection. He also says the Trust’s communication with his family was poor. Mr O complains the Practice did not identify that his injuries needed further investigation or provide medication to treat …

NHS in England Apr 2025

P-003737 — Medway NHS Foundation Trust

Mrs O complains that an administrative error on admission led to her sister receiving inappropriate care. She also complains about the Trust's communication, completion of the death certificate, and complaint handling.

NHS in England Aug 2025

P-003962 — Countess of Chester Hospital NHS Foundation Trust

Mrs H complains the Trust did not refer her husband for an oxygen assessment or lung function sooner, did not tell him he had pulmonary fibrosis, gave false reassurances and handled her complaint poorly.

NHS in England Upheld Aug 2025

P-003782 — Hull University Teaching Hospitals NHS Trust

Mr D complains about two hospital admissions his late mother had in April 2024. He said the way she was discharged from the first was unreasonable and that when she was readmitted soon after, he was not advised that she was close to dying.

NHS in England Aug 2025

21-013-351 — Nottingham City Council

Summary: We will not investigate this complaint that the coroner’s service failed to inform the complainants of the date of his daughter’s inquest. This is because the complaint is made late and because further investigation would not lead to a different outcome.

LGO (Local Government & … Other Categories Feb 2022

21-009-310 — Surrey County Council

Summary: Mrs X complained about how the Council managed the Coroner’s inquest into her father’s death. The Council was at fault when it both failed to invite Mrs X to the inquest and provide her with important documents prior to it. It meant Mrs X did not attend the inquest …

LGO (Local Government & … Other Categories Upheld Mar 2022

21-011-697 — Surrey County Council

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.

LGO (Local Government & … Other Categories Upheld Mar 2022

21-016-380 — Sandwell Metropolitan Borough Council

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.

LGO (Local Government & … Other Categories Upheld May 2022

21-018-329 — Surrey County Council

Summary: Mr X complains a Coroner did not do her job properly. He says wrong information was read out in court and the hearing was not recorded. We cannot investigate the actions of the Coroner or what happened in court. The Council has apologised for failing to record the hearing. …

LGO (Local Government & … Other Categories Upheld Apr 2022

21-005-590 — St Helens Metropolitan Borough Council

Summary: Mrs X and Ms Y complain about the Council’s handling following their uncle’s (Mr Z) death and its failure to inform them when his funeral was taking place. The Council was at fault for not following its own policy and government good practice in this case. This meant Mrs …

LGO (Local Government & … Adult Care Services Upheld Apr 2022

21-010-162 — Sefton Metropolitan Borough Council

Summary: Mrs Y complains about how the coroner’s office handled the inquest into the death of her late sister. We cannot investigate some of the matters complained about because they are outside of our jurisdiction. However, we found the coroner’s office failed to make an audible recording of the hearing, …

LGO (Local Government & … Other Categories Upheld Apr 2022

21-011-373 — Essex County Council

Summary: Mr X complains the Council has not dealt with his father’s death properly. The Council is at fault because it did not provide information, took too long to allocate a Coroner’s Officer and did not offer the opportunity to view the body. The Council has agreed to apologise to …

LGO (Local Government & … Other Categories Upheld May 2022

23-005-209 — London Borough of Camden

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.

LGO (Local Government & … Other Categories Upheld Mar 2024

23-019-595 — Durham County Council

Summary: We cannot investigate Miss B’s complaint about the decision made by the coroner on the cause of death of her brother and the coroner’s alleged failure to discuss the matter with Miss B. This is because we have no power to do so.

LGO (Local Government & … Other Categories Apr 2024

23-014-375 — London Borough of Lambeth

Summary: We will not investigate this complaint about the actions of the coroner’s office. We have no power to do so.

LGO (Local Government & … Other Categories Jun 2024

25-006-935 — Westminster City Council

Summary: We cannot investigate Ms X’s complaint about the actions of the coroners’ office. We do not have the power to investigate the actions of the coroner or the coroners’ office staff who complete administrative tasks on the coroners’ behalf.

LGO (Local Government & … Other Categories Aug 2025

25-007-568 — Royal Borough of Kensington & Chelsea

Summary: We cannot investigate this complaint about the coroner’s service. This is because the law does not allow us to investigate the actions of the coroner and their officers.

LGO (Local Government & … Other Categories Sep 2025

25-013-159 — London Borough of Waltham Forest

Summary: We cannot investigate Mrs X’s complaint about a coroner because the Council is not responsible for the actions of coroners and their officers who carry out coroners' functions, and we cannot investigate the actions of other bodies. We will not investigate the Council’s complaint handling because it is not …

LGO (Local Government & … Other Categories Oct 2025

21-014-254 — Somerset County Council

Summary: A care home providing care on behalf of the Council, made several unsuccessful attempts to contact Ms X to notify her of her father’s deteriorating health and his subsequent death. There is no fault in the care home then notifying the second recorded contact.

LGO (Local Government & … Adult Care Services Not Upheld Jul 2022

24-009-750 — London Borough of Camden

Summary: We will not investigate Miss X’s complaint about poor communication she experienced with a coroner’s officer. This is because their actions were not an administrative function of the Council.

LGO (Local Government & … Other Categories Oct 2024

24-012-375 — Somerset Council

Summary: We will not investigate this complaint about the Council’s decision not to share information relating to coronial proceedings. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. The issues Mrs X is complaining about are closely …

LGO (Local Government & … Other Categories Oct 2024

21-005-802 — Cambridgeshire County Council

Summary: Mrs B complained about her contact with the Council’s coroner’s office. She said the staff were unprofessional and lied to her family. We did not find fault.

LGO (Local Government & … Other Categories Not Upheld Mar 2022

21-018-378 — Nottingham City Council

Summary: We cannot investigate this complaint about conclusions made by the coroner into the cause of death of Miss X’s partner. Coroners are not employees of the Council and therefore its actions are not administrative functions of the Council.

LGO (Local Government & … Other Categories Apr 2022

21-013-154 — London Borough of Ealing

Summary: We will not investigate Ms C’s complaint about the Council’s failure to inform her of the death of her brother, Mr B, at the earliest opportunity. This is because there is not enough evidence of fault to warrant an ombudsman investigation.

LGO (Local Government & … Adult Care Services Jul 2022

22-005-549 — Staffordshire County Council

Summary: We will not investigate Mr X’s complaint about a care provider not releasing information to him regarding what happened on the day his mother was found unresponsive by her carers. This is because there is another body better placed to consider the complaint.

LGO (Local Government & … Adult Care Services Sep 2022

22-001-120 — Lancashire County Council

Summary: We will not investigate this complaint about the Council’s refusal to share a deceased person’s records with their executor. There is not enough evidence of fault to justify us investigating.

LGO (Local Government & … Adult Care Services Sep 2022

22-008-622 — Somerset County Council

Summary: We will not investigate this complaint about the Council’s failure to put Mr X’s complaint about the Coroner’s Office through its complaints procedure. We are unlikely to add anything to the substantive matter about the location of the inquest.

LGO (Local Government & … Other Categories Oct 2022

22-011-184 — Surrey County Council

Summary: We will not investigate this complaint about the actions of a coroner during the inquest into the death of the complainant’s mother. This is because coroners are not employees of the Council and therefore their actions are not administrative functions of the Council. Other elements of this complaint are …

LGO (Local Government & … Other Categories Dec 2022

23-017-815 — Surrey County Council

Summary: We cannot investigate Miss X’s complaint about decisions a coroner’s officer made during inquest proceedings because those decisions are outside our jurisdiction. And while we could investigate how the Council considered Miss X’s complaint about these matters, we should not investigate this, because there is no worthwhile outcome we …

LGO (Local Government & … Environment And Regulation Not Upheld May 2024

24-001-827 — Derbyshire County Council

Summary: We will not investigate Mr X’s complaint about the Council’s failure to keep him informed about his mother’s health, giving the keys to his mother’s property to another council without telling him, and taking away the opportunity for him to say goodbye to his mother. This is because there …

LGO (Local Government & … Adult Care Services Jul 2024

24-003-104 — London Borough of Croydon

Summary: We cannot investigate this complaint against the Council about the conduct of coroners involved in investigating the death of the complainant’s husband. We have no jurisdiction to investigate this complaint because the Council is not responsible for the issues.

LGO (Local Government & … Other Categories Jul 2024

24-006-635 — Westminster City Council

Summary: We will not investigate this complaint about a coroner. The coroner’s actions were as part of the coroner’s functions, and were not an administrative function of the Council. The matters complained about are therefore not within the Ombudsman’s jurisdiction.

LGO (Local Government & … Other Categories Sep 2024

24-000-751 — Gateshead Metropolitan Borough Council

Summary: We will not investigate this complaint about the Council’s actions following the death of a citizen. The Council was required to arrange a funeral, which it did. The Council acted to seek the next of kin. While we appreciate the distress for the next of kin, there is not …

LGO (Local Government & … Adult Care Services Sep 2024

25-002-071 — London Borough of Lewisham

Summary: We will not investigate this complaint about the Council’s failure to notify the complainant of the correct date for a funeral. This is because the Council will make a symbolic payment of £500.

LGO (Local Government & … Environment And Regulation Upheld Jul 2025

25-008-303 — Kent County Council

Summary: We cannot investigate this complaint about delays with coronial processes. Nor can we investigate Ms Y’s complaint about the conduct of the coroner. This is because these actions relate to coronial proceedings and are not an administrative function of the Council. Therefore, we have no power to investigate.

LGO (Local Government & … Other Categories Aug 2025

25-009-795 — Westminster City Council

Summary: We cannot investigate this complaint about the actions of the coroner’s office. We do not have the power to investigate the actions of the coroner or the coroner’s office staff because they are not acting under an administrative function of the Council.

LGO (Local Government & … Other Categories Oct 2025

24-008-373 — Birmingham City Council

Summary: We will not investigate Ms X’s complaint about what happened in the Coroner’s Court. That is because it is not an administrative function of the Council.

LGO (Local Government & … Other Categories Oct 2024

24-012-160 — Westminster City Council

Summary: We will not investigate this complaint about a coroner and the actions of a coroner’s office. This is because these actions are those related to a coroner’s function and are not an administrative function of the Council.

LGO (Local Government & … Other Categories Nov 2024

25-011-728 — Essex County Council

Summary: We will not investigate this complaint about the actions of a coroner and pathologist. Such actions are not administrative functions of the Council and are therefore not within our jurisdiction.

LGO (Local Government & … Other Categories Dec 2025

21-013-721 — Essex County Council

Summary: Ms X complains the Council has not dealt with her mother’s death properly. The Council is at fault because it did not provide information, delayed sending the death certificate and did not respond to Ms X’s complaint clearly. The Council has agreed to apologise to Ms X, pay Ms …

LGO (Local Government & … Other Categories Upheld May 2022

23-020-441 — Herefordshire Council

Summary: We will not investigate this complaint about the alleged failure of the Council to consider a complaint about the service provided by the coroner. We do not consider it a good use of public money to investigate complaints about complaint procedures, if we cannot deal with the substantive issue.

LGO (Local Government & … Other Categories May 2024

23-016-755 — City of Bradford Metropolitan District Council

Summary: We cannot investigate this complaint about the actions of the coroner’s office. We do not have the power to investigate the actions of the coroner or the coroner’s office which completes administrative tasks on the coroner’s behalf.

LGO (Local Government & … Other Categories May 2024

24-002-429 — East Sussex County Council

Summary: Ms K complained about the way the Council communicated with her late aunt’s family when it applied for Power of Attorney, and after her death. We found some fault in the Council’s actions after Ms K’s aunt’s death. The Council has already offered a fitting remedy, so we do …

LGO (Local Government & … Adult Care Services Upheld Sep 2024

24-007-208 — Liverpool City Council

Summary: We will not investigate Mr X’s complaint the Council withheld information from him about his mother’s, Mrs Q’s care. There is not enough evidence of fault to justify investigating.

LGO (Local Government & … Adult Care Services Oct 2024

24-002-920 — Surrey County Council

Summary: We will not investigate Miss X’s complaint about delays in a coronial process, or the actions of a coroner’s officer, because they are not an administrative function of the Council. Nor will we consider the suitability of a remedy the Council offered Miss X, because it is not a …

LGO (Local Government & … Other Categories Oct 2024

25-004-746 — London Borough of Barnet

Summary: We will not investigate Ms X’s complaint about the actions of the Council when she registered her father’s death. Further investigation would not lead to a different outcome.

LGO (Local Government & … Other Categories Upheld Jun 2025

24-012-225 — Cornwall Council

Summary: We will not investigate Ms X’s complaint about the Council’s handling of the registration of her relative’s death. It is unlikely we could add to the Council’s investigation or achieve a different outcome.

LGO (Local Government & … Other Categories Nov 2024

25-011-044 — Hertfordshire County Council

Summary: We will not investigate a complaint about a failure to tell a woman’s family when she died. Services provided coherent explanations for why they did not contact anyone. It is unlikely that an investigation would be able to find evidence of fault.

LGO (Local Government & … Adult Care Services Dec 2025

NIPSO-201916450 — South Eastern Health and Social Care Trust

The South Eastern Health Trust failed to tell a man about changes to his mother’s nutritional plan and the process of her palliative care.

NIPSO (NI Public Service… Health & Social Care Feb 2023

21-007-638 — Bournemouth, Christchurch and Poole Council

Summary: We cannot investigate this complaint about the verdict of a Coroner because we have no jurisdiction over the decisions of coroner’s. We will not investigate comments made by staff working for the coroners service, because we could not add to the Council’s investigation or achieve the outcome she wants.

LGO (Local Government & … Other Categories Jan 2022

21-018-069 — Calderdale Metropolitan Borough Council

Summary: Mr X complains about the handling of his objections made to the Council’s Bereavement Services about a cremation. He says he objected to the cremation of a deceased family member based on his beliefs and cultural reasons. We have decided to uphold Mr X’s complaint because there is evidence …

LGO (Local Government & … Environment And Regulation Upheld Aug 2022

22-006-354 — London Borough of Hillingdon

Summary: We will not investigate this complaint about information not being provided about a court case (to decide where the complainant’s family member should live). This is because the case has already been decided in court, so we have no remit to intervene.

LGO (Local Government & … Adult Care Services Sep 2022

22-010-130 — Derbyshire County Council

Summary: We will not investigate this complaint about administrative failings by the coroner’s officer. The complainant has not suffered personal injustice from these faults alone to justify an investigation. The Information Commissioner’s Office is better placed to consider complaints about access to information. Also, complaints about the coroner’s investigation are …

LGO (Local Government & … Other Categories Upheld Dec 2022

24-002-184 — Surrey County Council

Summary: We cannot investigate this complaint about the actions of the coroner’s office. We have no power to do so.

LGO (Local Government & … Other Categories Jun 2024