Judge rejects challenge to decision by Assistant Coroner not to hold Article 2 inquest into death of woman in fire at home

The High Court has rejected a judicial review challenge to an assistant coroner's decision not to hold an Article 2 inquest examining whether two public bodies had any responsibility for a woman’s death.

In Parkin, R (On the Application Of) v His Majesty's Assistant Coroner for Inner London (East) [2024] EWHC 744 (Admin)  Mrs Justice Collins Rice heard that 74-years-old Rosslyn Wolff was found dead in her home in January 2022, following a domestic fire, which London Fire Brigade concluded was probably caused by unsafe use or disposal of smoking materials.

Her son Gary Parkin made submissions to the assistant coroner in which he said his mother had been let down by the London Borough of Havering and North East London NHS Foundation Trust, which had both had recent dealings with her, and that their potential responsibility for the tragedy should be fully investigated.

He said Article 2 of the European Convention on Human Rights was engaged.

The Assistant Coroner for Inner London (East) declined to do this and Mr Parkin gained permission for a judicial review.

Collins Rice J was told Ms Wolff had lived on her own. Her domestic arrangements were irregular: she was a hoarder, and her home was filled with detritus and debris and was unhygienic.

London Fire Brigade reported multiple referrals for home safety visits, which it had tried unsuccessfully to make on several occasions until November 2019 when she agreed to have smoke alarms fitted.

Ms Wolff had come to the attention of Havering social services in mid-2019, after Mr Parkin raised concerns about her self-neglect and poor living conditions.

An initial multidisciplinary assessment found no mental health concerns but she agreed to a care package to support personal hygiene and medication compliance.

In a brief ruling the assistant coroner said: “Public bodies such as healthcare foundation trusts and municipal corporations are embodiments of the state for the purposes of recognising the possible application of Article 2 obligations. But the bare fact that such institutions may have interacted with the citizen does not thereby determine whether Article 2 is engaged.

“The relevant situations must be identified. That entails a consideration of whether there is evidence to suggest that Rosslyn was at the time of her death in state detention or in real and immediate risk to her life. Neither of those situations is shown on the evidence. The evidence is that she lived in her own home. She had declined additional intervention by the state. Her mental capacity had been assessed and she was deemed to have capacity. She was therefore entitled to exercise choice. She had the right to take unwise or inappropriate decisions. The state does not take on added duties or responsibilities in such circumstances.”

The evidence did not support the application to engage Article 2, and any shortcomings or failings which might be established could be investigated within a Jamieson inquiry and scrutinised if necessary within a Report to Prevent Future Death, or even a finding of neglect if the evidence proved as much, they added.

Mrs Justice Collins Rice said her task was to consider whether it was arguable – “credible, not fanciful” – on the facts of the case that any state agencies involved with Ms Wolff breached an Art.2 operational duty towards her.

“If it is, the section 5(2) necessity test is passed. Whether there is an arguable breach in turn depends on identifying whether such a duty arose in the first place and, if so, its scope.”

Mrs Justice Collins Rice said the condition of Ms Wolff’s home was such that the assistant corner had been wrong to conclude there was no ‘real and immediate risk of death’ and the high threshold test for this was met.

But the judge said the state had no verifiable power to control or detain her and it had been professionally established there were no Mental Health Act powers to do so.

Collins Rice J said: “I was shown no authority on Art.2 which comes close to supporting the establishment of the positive operational duty on the basis of the existence of a welfare plan, even one relevant to managing a risk to life.

“No doubt the public authorities in this case owed professional duties to Ms Wolff. But it is not every case in which health and social care professionals draw up care plans for individuals, or patients spend time in hospital, that the Art.2 duty arises.”

She had to bear in mind that Ms Wolff “was an adult of confirmed competence and psychiatrically sound mind,” and “I was shown no decided authority in which properly autonomous risk to the self was nevertheless made subject to implied transfer to the state by way of the Art.2 duty. On the contrary, the authorities point to the two being mutually exclusive.”

The judge said the evidence was that Mrs Wolff was “a fiercely independent lady of sound mind who did not want well-intentioned health and social work professionals judging or interfering with a lifestyle she was well aware was a risky one.

“The tragic circumstances of her death, and the natural dismay that this was, on at least some level, an avoidable disaster befalling an unfortunate and perhaps disadvantaged individual, do not mean it was one which it was the duty of the state to prevent.”

Applying the standard of reasonableness, it was not arguable that the council and the trust breached the Article 2 duty on the facts of this case.

Collins Rice J concluded: “My conclusion is that the Art.2 positive operational duty did not arise on the facts of this case. But even if it did, I do not consider it arguable that any statable duty was breached. That means that the necessity test for holding an inquest under section 5(2) is not satisfied and the assistant coroner’s decision must stand.”

She added: “As the assistant coroner explained, that does not necessarily mean that the matters about which Mr Parkin is concerned cannot be addressed by other means. Issues of potential shortcomings or failings leading up to Ms Wolff’s death can be investigated.”

Mark Smulian