The King (on the application of) Mr Gary Parkin v HM Assistant Coroner for Inner London (East)

Hearing date: 19 th March 2024

Approved Judgment

This judgment was handed down remotely at 2pm on 28 March 2024 by circulation to the parties or their representatives by e-mail and by release to the National Archives.

THE HONOURABLE Mrs Justice Collins Rice

Introduction

Mrs Rosslyn Wolff was found dead in her home on 11 ^th January 2022, following a domestic fire. She was 74 years old. The primary medical cause of her death was given as smoke inhalation; secondary medical factors were ischaemic heart disease and diabetic ketoacidosis.

A London Fire Brigade investigation team report of 9 ^th June 2022 concluded the most probable cause of the fire was unsafe use or disposal of smoking materials. The fire was mostly limited to the sofa where Mrs Wolff's body was found. Cigarette butts and empty cigarette packets were nearby.

An inquest into her death was formally opened on 27 ^th January 2022 by HM Assistant Coroner for Inner London (East).

At a Pre-Inquest Review hearing on 16 ^th August 2022, Mrs Wolff's son, Mr Gary Parkin, made a number of submissions to the Assistant Coroner. Among them, he expressed concerns that his mother had been let down, in the weeks and months leading up to her death, by one or more of the public authorities who had had recent dealings with her, and that their potential responsibility for the tragedy should be fully investigated. He asked for the inquest to be broadened out to consider not just the causes of his mother's death, but all the circumstances of it, on the ground that Article 2 of the European Convention on Human Rights was engaged. By a ruling dated 1 ^st September 2022, the Assistant Coroner declined to do so.

Mr Parkin has permission for a judicial review of that decision. The Assistant Coroner is the named defendant but, as is usual, formally takes a neutral position (Leading Counsel instructed by the Assistant Coroner attended the hearing of the review to assist the Court). The public authorities Mr Parkin wishes to have the inquest investigate – the local healthcare trust and local authority social services department – attended as interested parties.

The inquest stands adjourned meanwhile.

Factual background

The following factual background is uncontroversial and appears from the documents before the Assistant Coroner.

Mrs Wolff had lived on her own. Her domestic arrangements were irregular: she was a hoarder, and her home was filled with detritus and debris. It was not maintained or kept hygienic. The London Fire Brigade reported after the fatal incident that it had had multiple referrals for home safety visits over the years. It had tried unsuccessfully to make a visit on 8 or 9 occasions – Mrs Wolff had either refused the visit or had been unable to be contacted. But a visit had successfully been made on 27 ^th November 2019 and smoke alarms fitted. It was the smoke alarms that alerted neighbours and the fire brigade to the fatal fire.

Mrs Wolff had come to the attention of her local authority social services in mid-2019, after Mr Parkin raised concerns about her self-neglect and poor living conditions, and about her abusive treatment at the hands of another family member (who in turn was known to the local mental health service). An initial multidisciplinary assessment was carried out: no mental health concerns were identified in relation to Mrs Wolff herself, but ‘ after much persuasion’, she agreed to a care package to support personal hygiene and medication compliance.

As well as being a smoker, she was diabetic. On two occasions in September 2021 she had been detained briefly under the Mental Health Act 1983, but her symptoms of confusion were then diagnosed as not proceeding from mental ill health but from hyperglycaemia – the result of not maintaining her diabetes medication regime. (It was noted during her hospital stay she ‘ did not comply with nursing interventions, refused her COVID PCR test and would not allow doctors to conduct any physical examinations’.) The post-mortem report also indicated that her diabetic condition at the time may have played a part in the fire and her possible inability to get up from the sofa and do anything about it.

On 7 ^th October 2021, a multi-agency risk assessment conference of health and social care professionals reviewed Mrs Wolff's circumstances. They noted no concerns over her mental health or capacity, but noted ‘ ongoing risk presented by her unwise decision making’. These included that she had been ‘ adamant in her expression of not wishing to engage in conversations about her environmental circumstances’ – which included concerns about the state of her home: poorly looked-after dogs, dog mess, risk of electrical injury, risk of leaking water. It was noted there had been some progress with engagement with her allocated social worker, but this had had to be ‘ very gentle’ – ‘ Rosslyn does not respond well to multiple offers of help or professional involvement’. An action plan was agreed, to include continued offers of follow-up and engagement with her social worker, and a fire assessment was to be made of her home by the fire brigade.

The social worker visited on 13 ^th October 2021. Mrs Wolff refused to open her door, and declined offers of help with getting her house cleaned or garden cleared. The social worker visited again on 15 ^th October, to much the same effect. On further visits on 26 ^th October, 1 ^st November and 15 ^th November, the social worker was unable to elicit any reply at all.

Further multidisciplinary review meetings were held on 22 ^nd October and 1 ^st December 2021. The social worker attempted a visit on 9 ^th December 2021, and observed the state of the house through the windows, but received no reply or admission. A last professionals' meeting was held on 10 ^th December 2021. The record of it includes this:

NELFT [North East London NHS Foundation Trust] and ASC SW [Adult Social Care Social Worker] provided feedback from attempted visit the previous day. They advised of the fire risk due to the state of the property. The professionals explored options available including whether there were any legal grounds upon which the police or ASC could enter Rosslyn's home without her consent and during her absence. Actions were allocated to various members of the MDT [Multi Disciplinary Team] by Director ASC, including a repeat attempt to visit and assess mental capacity.

The NELFT named professional for safeguarding adults suggested an experienced practitioner from the OAMHT [Older Adults Mental Health Team] support ASC with their next visit, so that a MHA [Mental Health Act] assessment could be carried out at the same time if Rosslyn was home.

There were no formal minutes recorded in the EPR (electronic patient record) or uploaded into CareDoc regarding this meeting, therefore not all actions are clear.

It is not completely clear from the evidence so far whether the fire assessment commissioned at the 7 ^th October meeting did take place but was not recorded as such, or did not take place. In its own subsequent investigation into the circumstances of Mrs Wolff's death, NELFT recorded the following:

Care and service delivery problems

Risk assessment

— The risk assessment completed for Rosslyn on the 11/10/2021 identified that Rosslyn's overall risk was low despite significant ongoing risks relating to self-neglect, hoarding, non-engagement and domestic abuse

— …

— There was no fire assessment completed despite it being known Rosslyn was a hoarder and a smoker which does not align with the recommendations in NELFT safeguarding Standard Operating Procedure (SOP)

Assessment

— …

— At the professionals meeting on the 07/10/2021, it was documented that an action for a fire assessment to be triggered for the London Fire Brigade to review Rosslyn's home was to be completed. There is no evidence that this action was completed within the EPR however information provided by the ICD confirms that this action was assigned to ASC and was actioned, but records do not reflect this.

— At the professionals meeting held on the 10/12/2021 there was a plan for a second joint unannounced home visit to be carried out by reference for Rosslyn to be offered a home visit with the adult social worker and an experienced OAMHT practitioner who could undertake a MHA [Mental Health Act] assessment. There is no evidence that the home visit was completed, and no sound explanation was provided to the IO [Investigating Officer] during staff interviews for delays in arranging this visit.

— …

Root Cause/s

The fundamental root cause of Rosslyn's death was a small, localised fire at her property. The fire risk was evident to all professionals working together across adult social services, the police and health. Rosslyn was known to be a hoarder and although it is acknowledged that ASC completed fire risk assessments, these were not shared with NELFT which meant that this risk was not thoroughly reflected in assessments within the EPR. Rosslyn was often referred to as vulnerable however attempts to safeguard her were...