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.

The complaint

1. Miss B complains the coroner’s decision on the cause of death of her brother doesn’t give answers about what happened to him. She questions the thoroughness of the post mortem and says she wants the cause of death changed to be more specific.
2. Miss B also complains she could not discuss her concerns about the coroner’s decision with anyone who is medically trained, and cannot register her brother’s death until they are resolved.

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The Ombudsman’s role and powers

3. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
4. We cannot investigate complaints about actions which are not an administrative function of the council. (Local Government Act 1974, section 26(1) as amended)
5. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies or office holders such as coroners and coroners’ officers carrying out their functions. (Local Government Act 1974, sections 25 and 34(1), as amended)

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How I considered this complaint

6. I considered information provided by the complainant.
7. I considered the Ombudsman’s Assessment Code.

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My assessment

8. The role of the coroner is to investigate unexpected deaths and give findings on what they consider to have been the cause.
9. Coroners are judicial office holders carrying out their own functions as set out in law. The council for the relevant area appoints a coroner, funds the service, and provides accommodation, and provides staff to the extent the police do not.
10. We can only consider a complaint about the Council’s limited functions in relation to coroners. We cannot investigate the actions taken by a coroner or their officers because they are about the coroner’s functions not the Council’s.
11. People may complain to the Judicial Conduct Investigations office about the conduct or actions of a coroner. They may also complain to the relevant police service and then the Independent Office for Police Conduct about the actions of coroner’s officers provided by the police. A coroner’s decision can only be challenged by Judicial Review at the High Court.
12. It is clear Miss B is unhappy with the coroner’s decision into the cause of death but we cannot investigate how they reached their decision or whether it is correct. We cannot therefore achieve the outcome Miss B wants, which is to change the coroner’s report to list a different cause of death. If Miss B wishes to challenge the decision she may wish to seek legal advice.
13. I recognise Miss B is also unhappy she wasn’t able to discuss her concerns about the cause of death with someone who was medically trained, but this is about a function of the coroner, not the Council. If Miss B wishes to complain about other aspects of the coroner’s or their officers’ actions, she may complain to the Judicial Conduct Investigations Office or the police service for the area.

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Final decision

We cannot investigate this complaint. This is because the main issue concerns the coroner’s findings or officer actions on their behalf, and we have no power to investigate them.

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Investigator's decision on behalf of the Ombudsman