Woman cremated without brain in 'extremely distressing' post-mortem blunder

Her brother – referred to as ‘Mr X’ in a Local Government and Social Care Ombudsman (LGSCO) report – said the error caused him and his family distress knowing their loved one was ‘not whole’ at her funeral in August 2021. He also claimed they suffered financial loss through travelling to scatter her ashes for a second time.

As the funding authority of the coroner’s office dealing with the deceased, Sandwell Council accepted fault. Mr X was awarded £500 for distress caused and a further £100 in travel costs.

The LGSCO probe revealed the coroner’s office received a cause of death form from a pathologist for Mr X’s sister – referred to as ‘Ms Y’ – in July 2021. The report stated: “This form detailed the pathologist had removed the brain from her body as part of histology samples for a neuropathology examination.

“At the beginning of August 2021, Ms Y’s body was cremated. By mid-August, the coroner’s office became aware Ms Y’s brain had removed from her body. The office contacted Mr X and his family immediately to discuss the error.

“In a meeting, Mr X confirmed to the office that the family wanted Ms Y’s brain to be cremated so they could reunite the ashes with the existing ashes. The office agreed to make all the arrangements for this.

“In December 2021, the hospital released Ms Y’s brain. The coroner arranged and paid for the cremation.

“Mr X said he had to travel again to scatter the ashes to reunite them with the other ashes. Mr X said this was an extra cost to him and his mother.

“In response to our enquiries, the coroner confirmed the error was due to a member of staff not identifying from the cause of death form the pathologist had removed the brain.”

The coroner told LGSCO it had set up a new case management system to manage referrals in light of the complaint. Within this system, where whole organs are removed, it is now documented and tasked for staff to have a discussion with the family to allow them to consider their options on how to proceed.

A coroner officer also completed one-to-one coaching with all staff, including the worker who made the error. This was to highlight the process staff should follow where organs are removed.

As part of the coaching, Sandwell Council reminded staff to be vigilant in reading instructions on all forms, including cause of death forms. In the report, LGSCO summarised the case stating: “It is clear there was fault as the coroner’s office failed to tell Mr X and his family that Ms Y’s brain was not with her body.

“This meant they cremated Ms Y’s body without her brain. We recognise this would have been extremely distressing for Mr X and his family.

“In response to Mr X’s complaint, the council, accepted it was at fault and noted it had arranged to cremate the brain. The council also apologised and offered a financial payment.”

A Sandwell Council spokesperson said: “As soon as the Coroner’s office became aware of what had happened, they contacted the family immediately to let them know and offer their sincere apologies.

“A full investigation was then carried out to understand how this had happened and the family were provided with a detailed response on the findings from the investigation and actions that had been taken.

“The Ombudsman later reviewed the matter and recognised that staff took prompt action to ensure the family’s distress was not increased or prolonged and made changes to avoid this happening in the future. This was acknowledged in the Ombudsman’s findings published in May 2022.

“Action taken in 2021 included the Coroner’s office making all the arrangements and paying for a further cremation to reunite the ashes with the other ashes.

“Changes made, also acknowledged by the Ombudsman, included a new case management system and coaching for all staff.

“£600 was paid in full to the family once the Ombudsman’s decision came in.

“The Ombudsman confirmed in June 2022 that there were satisfied all actions had been carried out and the case was complete.”