Inspector of Funeral Directors: annual report 2017-2018

4. Update on complaint management, investigations or good practice discussions

Since appointment, there have been a number of complaints received regarding the behaviour or actions of funeral directors, or self-notification of incidents from businesses themselves looking for advice and support. In addition, discussions around improving links and good practice have also been held. Summary details of these are described below for reference, and are purposefully anonymous to avoid any possible distress to the bereaved.

• During bad weather and elongated recovery period in early 2018, a number of concerns raised regarding the impact on care and storage of the deceased, impact and notification of funeral cancellation, including the impact of local authority closures for cremation or burial services. Also a small number of concerns rose regarding ability of families to access registrars’ services for death registration. It should be noted that the system coped with additional demand, but my observation is that was as a result of parts of the system implementing local ad-hoc solutions to overcome challenges – much to their credit. Feedback information has been provided to resilience colleagues within Scottish Government.

• Follow up on a misidentification case which was self-referred by a funeral director, where two deceased of same name in the NHS mortuary. This information was not notified to the funeral director’s staff. In addition internal investigations established that identity checks were not adequately carried out. The result was the wrong deceased was prepared and coffined, when the second funeral director realised the error. Understandably, on notification, the family were deeply distressed, and had a strong desire to be reassured that this would not happen again. The funeral director involved self-reported to the Inspector with no legal requirement to do so, and initiated an internal disciplinary investigation. In liaison with myself, the funeral director also carried out a review of identification procedures and now has incorporated a three point randomised identity check as part of the company software system being developed and rolled out. The NHS team also carried out a review of the circumstances and report was produced, however were somewhat less proactive in reassuring me that the improvement actions would be followed through.

• Informal notification received from a crematorium that a funeral director had presented a coffin for cremation with leaking bodily fluids. This resulted in the crematorium catafalque being contaminated, and this impacted on the presentation of a second coffin from an unrelated funeral which was damaged as a result. Enquiries are on-going.

• Case reported by a crematorium when a funeral director was reported to have presented a damaged coffin for cremation with a marker pen name plate. Follow up initiated and funeral director admitted this was the case. They received advice in a written report that this is not acceptable. Funeral director accepted this was not an appropriate solution to the situation which had emerged in attempting to deliver the funeral.

• Current case being investigated into the manner of which a funeral director took the deceased into their care during night time hours using a procedure which would not be deemed as best practice. This situation had been informally reported to a third party funeral director, and subsequently referred to myself for investigation. Enquiries are on-going, and if this practice is substantiated, it would be deemed to be unacceptable and a formal letter will be prepared and issued.

• During the course of an introductory inspection, operational practices observed were such for the care of a deceased that should formal powers have been available then an improvement notice would have been immediately prepared. A concerted response was required and I’m pleased to say that on discussion with the funeral director involved as to the seriousness of the concerns, a scheduled revisit six weeks later evidenced a significant improvement in practice. On-going monitoring will be in place over the coming months to ensure that this is sustained.

• Discussions held with a funeral director with regard to improving practice for local authority funerals, leading to my input being provided for the Scotland Excel funeral services specification.

• Concern raised by a funeral director in relation to the condition of a body following post mortem, raised formally with the Crown Office and Scottish Government, enquiries have concluded and a formal response sent .

• Informal dialogue with NHS colleagues on-going in relation to care of deceased infants who are taken home by parents until the funeral. There is a collective desire to ensure on-going strong links and communication between all professionals in these circumstances to facilitate the family wishes.

• Contact made via an MP’s office from a bereaved mother who has concerns regarding the funeral service provision for her adult son. This case is in an early stage of review to establish details of the concern and enquiries are on-going.

• A small number of formal and informal complaints received regarding quality of care of deceased in a public mortuary. Locally implemented stakeholder forum in place to improve practice and joint working.

In late 2017, the Scottish Government chaired a meeting of trade bodies and the Inspector of Funeral Directors to discuss the interface between complaint management processes to ensure appropriate responses are in place for the bereaved, effective use of resources and lessons are learned and shared. These constructive discussions are on-going, and further details of the agreed model and protocol will be developed.