Gary Parkin had waited three years to enter the witness box at his mother’s inquest.
A wheelchair-bound amputee, he declined coroner Ian Wade KC’s offer to let him testify from a desk in the well of the court. He insisted instead on pulling himself up into the box, so he could face the people to whom he would direct his ire.
His mum, 74-year-old Rosslyn Wolff, died in a house fire in Myrtle Road, Harold Hill, on January 11, 2022. Her inquest finally began on January 13, 2025.
“The circumstances of her passing have proved somewhat controversial,” Mr Wade said in his opening remarks.
The hearing was delayed while Gary, 56, took the case to the High Court, seeking a jury inquest into alleged failures by the state.
For three years, the Romford Recorder attended every court hearing, where evidence was presented that Rosslyn lived in unimaginable squalor.
Her family told local agencies her home was filled with mouldering dog faeces and she was suffering from apparent dementia, seemingly incapable of understanding the harm her living conditions were likely to cause her.
The High Court called Rosslyn’s death a “harrowing” and “avoidable” tragedy, but found the state had not accepted any duty to intervene. The case was sent back to East London Coroner’s Court in Walthamstow.
Over two days, Mr Wade heard evidence about the months and years preceding Rosslyn’s death. Havering Council, North East London NHS Foundation Trust (NELFT) – the local mental health trust – and one of NELFT’s psychiatrists were all represented by barristers.
“It’s a shame all these people who’ve turned up for the inquest didn’t show up to help my mum when she was alive,” Gary muttered.
He was last to give evidence.
“The people that are involved should hang their heads in shame for what you did to my mother,” he said, raising his voice. “You did nothing.”
But that wasn’t completely true.
It wasn’t just Gary who felt his mother was mentally ill. Several state agencies actually shared his opinion.
But, various courts have heard, the law left them all with their hands tied behind their backs.
It all came down to one complex issue: mental capacity.
This is the story of how a former Romford paralegal’s horrific death laid bare the difficulties loved ones and public bodies face when trying to save the life of somebody whose mental health issues defy categorisation.
* * *
Gary Parkin went to the High Court in pursuit of a jury inquest to decide whether the authorities had failed his mother – but the legal bar was so high he couldn’t overcome it (Image: Charles Thomson) In the early hours of January 11, 2022, Susan Wrenn was watching a film on Netflix when she heard a beeping sound. She got up, opened her window and smelled smoke. When she looked to the left, she noticed a haze in the air.
She rushed downstairs and out the back door, where she saw black smoke coming from her next-door neighbour Rosslyn Wolff’s home. She called 999.
Interviewed later by fire investigators, Susan’s son said he too had heard the beeping noise, plus “a short scream” and “a banging sound”.
Coroner Ian Wade KC would ultimately find that scream had been emitted by Rosslyn when she realised her living room was on fire.
The fire brigade was first on the scene. Oddly, they found Rosslyn’s front door padlocked shut from the outside. The back door was locked from the inside, with the keys still in the lock.
They forced entry and found Rosslyn laying supine on a sofa, already dead.
“On arrival, London Fire Brigade (LFB) advised fire extinguished, one female in property, obviously deceased,” wrote paramedic Benjamin Miller.
“Did not enter property as fire embers still being extinguished by LFB and patient visible from doorway.”
Rosslyn was pronounced dead at 1.47am.
Her body was “surrounded by discarded rubbish and cigarette butts”, noted Police Sergeant James Shopland.
But investigators decided to wait until daylight to start a thorough investigation.
* * *
The walls were heavily soot-stained. The bulbs had shattered in the heat. The blaze had knocked over her TV.
So far, so normal.
But, said Mr Manning, “It was a chaotic house in terms of how it was organised.”
That was putting it mildly.
She was found laying on the longer of two sofas. All along the top of it were old cigarette packets. Everywhere Mr Manning looked, he saw discarded cigarette butts.
He said: “There comes a point where I just couldn’t give you a figure.”
The court heard the total was likely in the “thousands”.
There was evidence of lit cigarettes habitually carelessly discarded. Mr Manning noticed “elongated burns”, suggesting cigarettes had been “dropped and slowly burnt along the floor”.
Cigarette butts were heaped in piles. Rosslyn had sometimes added to them without putting the cigarettes out first. They could see that from burn patterns.
Investigators also found scorch marks from multiple previous small fires in the house, evidently extinguished before they could grow out of control.
Fire investigators concluded that as Rosslyn laid on her longer sofa, a lit cigarette had somehow fallen onto her second, shorter sofa. That was the seat of the fire.
Meanwhile, police were starting to build a picture of Rosslyn and her lifestyle.
Neighbours told officers she “led a bit of a reclusive lifestyle” and had “potential dementia”.
Her family – and state agencies – had raised concerns years earlier that she might die in a fire.
* * *
Growing up, he said, Rosslyn had been “house-proud”. Now her home was filled with dog faeces and fleas. It was clear she was making no effort to clear it up. When he broached the subject, she denied it was a problem.
He had started noticing his mother’s declining mental state around two years earlier, but hadn’t realised things were this bad.
He and his aunt – Rosslyn’s sister – became convinced there was something seriously wrong with her. They suspected dementia, which Rosslyn’s mother had died of. Her behaviour was otherwise inexplicable: her decisions were totally at odds with her own best interests.
Desperate, Gary sent more than 40 photos of his mother’s shocking living conditions to Havering Council and NELFT.
They visited and found the home “extremely dirty”. Rosslyn had “dirty clothes” on and admitted she hadn’t washed in three weeks. She initially agreed to accept help – but then failed to cooperate.
LFB also noted concerns in 2019. When firefighters attended to install smoke alarms, they were so disturbed by the squalor that they raised a safeguarding report.
Rosslyn began regularly missing medical appointments. She had Type 2 diabetes and her GP repeatedly recorded that she was not managing it properly.
In 2020, Havering tried to seek permission from the Court of Protection to intervene, but was advised that it had insufficient grounds: there was no formal evidence – no diagnosis – that Rosslyn lacked mental capacity to make her own decisions.
In August 2021, Rosslyn’s GP noted during an appointment that her feet were so dirty it looked like she never washed them at all.
“Difficult to talk to Rosslyn,” they recorded. “She talks over you and quite angry today.”
The following month, the GP added that Rosslyn had “possible mental health difficulty”.
“I am concerned that she is at risk,” they wrote.
* * *
A few days later, Elaine Hays-Patten noticed somebody standing on her doorstep. It was her next-door neighbour Rosslyn. She invited Rosslyn inside for a cup of tea, to see if she was okay.
“She was talking in bits,” Elaine wrote in a statement for the coroner.
“They took my boundary!” she recalled Rosslyn exclaiming. “I bought the house from Mr Wallace! I know my rights!”
Rosslyn was clutching some paperwork and told Elaine she was a paralegal. In truth, she hadn’t worked as a paralegal for 25 years.
This would become a preoccupation in Rosslyn’s final months. She would continually complain that shadowy figures were conspiring to steal her land.
Also in early September, Rosslyn was observed travelling back and forth between two north Essex train stations, seemingly lost and confused.
When police approached her, she shouted that they wanted to kill her and accused them of trying to steal her land registry documents.
After detaining her under section, officers visited her home and found it full of dog faeces.
It was now two years since Gary had first reported to Havering and NELFT that his mother’s home was full of dog poo.
But a doctor decided Rosslyn was not unwell enough to justify further detention.
She was sent home, to a house so filthy that police and the RSPCA had broken in to rescue her dogs from the uninhabitable conditions.
That was why, when the fire brigade arrived on the night of her death a few months later, it was locked from the outside with a padlock. The police had called in a security firm to secure the door after they busted through it.
Rosslyn had refused to have it repaired, despite Gary’s pleas.
* * *
This time, after being found wandering confusedly around Cambridgeshire, a prolonged detention was authorised.
She was initially taken to Hinchingbrooke Hospital, where staff told Gary they thought she had dementia.
After a few days, she was transferred to NELFT’s Woodbury Unit at Whipps Cross Hospital.
There, she largely refused to cooperate with staff. Described in notes as “suspicious and not engaged”, she refused a Covid test or regular blood tests and often didn’t take her medication.
Carol White – NELFT’s integrated care director at the time, who had liaised extensively with Havering Council about Rosslyn’s case – contacted consultant Dr Essam Kamel with her concerns.
If discharged, she said, Rosslyn would be “returning to a house with dog faeces” and “could die”. She felt Rosslyn posed a risk to herself and suggested her mental capacity be tested.
Dr Kamel mentioned the dog faeces when he next spoke to Rosslyn. She denied there was any in her home. But when he said living with dog poo “can be harmful”, she retorted: “No it’s not!”
“I don’t recognise your authority!” she told him. “You’re just a nurse! You’re not a doctor!”
She accused another doctor of being “from the police station” and continually told Dr Kamel: “I don’t want to see you! Clear off!”
Despite this, Dr Kamel told the coroner: “I could not observe any psychotic illness or depressive disorder.”
After a week, he felt Rosslyn could no longer be lawfully detained. Just because she was “idiosyncratic” and “a free spirit”, he said, that didn’t make her mentally ill.
“This is part of her personality,” he testified. “She had capacity to decide. We can’t force treatment or our advice on her.”
After being informed she was no longer detained, Rosslyn was given the option to stay on voluntarily until a package of her regular medications was ready.
She declined, saying she’d go home and come back for it.
She never returned.
* * *
In the meantime, Havering social services requested a fire assessment of Rosslyn’s home.
London Fire Brigade attended but got no answer. Seeing the padlock and chain on the front door, they removed Rosslyn from their system “because it appeared that she had been relocated.”
The social worker, realising LFB’s mistake, referred Rosslyn again less than two weeks later – but in doing so, made their own mistake. They sent it to Essex, not LFB.
That was the last anyone ever heard about a fire assessment.
Querying the importance of this error, the coroner pointed out that there had already been an assessment in 2019 and firefighters had installed smoke alarms with a ten-year battery life.
But barrister Ben McCormack, representing Gary, reminded the court that when firefighters had done that last assessment, the shocking conditions prompted them to also file a safeguarding report.
Mr Manning testified that it was “absolutely” possible this would have happened again, had the second assessment gone ahead.
Would firefighters have raised concerns if they entered Rosslyn’s home and found “thousands of cigarette ends”, asked Mr McCormack?
“That would be quite striking and they should do something about it,” Mr Manning confirmed.
* * *
Meanwhile, Havering and other NELFT staff were already plotting their own next steps.
Not everybody at NELFT had agreed with Dr Kamel.
Eva Donso, a nurse from the community mental health team, had visited Rosslyn at the unit and felt she “continues to require ongoing assessment”.
“I do not believe Mrs Wolff has insight into the extent of her difficulties,” she noted.
Helen Davie, an adult safeguarding nurse, had similar concerns, fearing Rosslyn “may not always have the capacity to execute what she needs to in order to manage her diabetes”.
Barbara Nicholls, Havering’s director of adult safeguarding, told the inquest that just because Rosslyn had capacity to decide on her detention, it didn’t mean she had capacity on all issues.
“It’s decision-specific,” she testified. “It’s not appropriate to do a blanket assessment of mental capacity. What’s important is to understand the decision that you are looking for that individual to make.”
In particular, Havering and NELFT were concerned Rosslyn had demonstrated an ongoing inability to make safe decisions about her welfare. The grounds for this belief were self-evident: she had been living for years in a house filled with dog faeces.
They decided “to try and engage with Rosslyn to be able to gain access [to her home]” and “do as good a mental capacity assessment as we could”.
Rosslyn remained uncooperative. When they attended on October 13 and 14, she sent them away. Every time they returned after that, nobody answered.
During one visit, a neighbour voiced concern that Rosslyn wasn’t looking after herself properly.
Finding the porch full of unopened mail, the professionals peered through a window into her lounge and saw it was “very dirty”. A chair was “piled high with cigarette butts on the seat”.
Through another window, they observed a kitchen so full of rubbish there were “no clear work surfaces” and “no sign that it had been used recently to prepare food”.
On December 10, Havering and NELFT held a meeting to discuss asking the Court of Protection or the High Court for legal power to forcibly intervene.
Lawyers said they didn’t have enough evidence and would need to try to engage with Rosslyn at least a few more times before approaching the courts.
The law requires a formal finding that a person doesn’t have mental capacity, or strong evidence that a person would be found to lack capacity if they weren’t refusing to be assessed.
But, said Mrs Nicholls, the intervention was waylaid by a new Covid-19 variant: Omicron.
The previous winter, the “Kent variant” had “spread like wildfire” to Essex, then Havering, wreaking havoc on the NHS.
When Omicron was discovered, councils had to spring into action, doing all they could to help clear hospital beds through provision of care at home or in care facilities, in case of a new wave.
Amid that chaos, nobody ever visited Rosslyn’s home again.
Ultimately, Omicron didn’t spread like the Kent variant – but Mrs Nicholls said Havering couldn’t have foreseen that. She was satisfied she had deployed her resources in the most appropriate way.
“It was very devastating to us as a service and to the social worker in particular to learn of Rosslyn’s passing,” she testified.
* * *
Her death triggered an internal investigation by NELFT, which found a series of failings in the way her case was handled, particularly during her stay at the Woodbury Unit.
“Rosslyn was often described in the clinical notes as appearing paranoid, confused and guarded, yet the clinical team on the ward concluded in their assessments that there was no evidence of mental illness,” the report said.
“There was frequent mention of executive capacity, however there were no executive functioning assessments completed during Rosslyn’s time on the ward… Rosslyn’s Section 2 Mental Health Act detention was rescinded during her admission despite evidence of her paranoid ideation, confusion and disengagement with treatment.”
It continued: “Rosslyn was described in her Section 2 paperwork to have issues with her short-term memory. Rosslyn’s mother had died from dementia aged 80 and she was reported to be confused on the ward. There were no formal cognitive assessments undertaken or documented… to rule out memory concerns such as dementia.”
Gary testified that he believed Hinchingbrooke had been nearer a correct diagnosis than Woodbury.
“They thought it was a dementia diagnosis,” he said. “That’s why they sectioned her. I believe Hinchingbrooke got it right.”
* * *
Pathologist Dr Ali Alhakim’s main conclusion was unsurprising: Rosslyn died from smoke inhalation.
Only small areas of her body were burnt, but there was soot in her mouth, nose, trachea and airways.
His internal inspection found Rosslyn had severe ischemic heart disease and an artery which was 95 per cent blocked – a condition which, on its own, could have killed her at any time.
But her blood tests revealed something else: ketoacidosis – almost two times the safe level of ketones were in Rosslyn’s blood, making it acidic.
A common side-effect of poorly-managed diabetes, symptoms can include confusion, drowsiness, coma and even death.
This, for Mr Wade, made sense of two things he hadn’t been able to reconcile: Mrs Wrenn’s son hearing Rosslyn scream, but Rosslyn making no attempt to escape.
He concluded ketoacidosis prevented her from reacting appropriately when she discovered the fire.
It was even speculated by witnesses that Rosslyn’s poorly-managed diabetes might be the root of all her erratic behaviour.
Mr Wade ruled Rosslyn’s death an accident and declared all Gary’s concerns about inaction by state agencies “irrelevant”.
“It would have occurred as it did even if Rosslyn had only ever smoked that one single cigarette in her whole life,” he said.
He declared that Rosslyn “was not mentally ill” and said he disagreed with the findings of NELFT’s internal investigation.
“She was entitled to live the life that she chose,” said Mr Wade. “The law protected that right.”
* * *
Surely his mum couldn’t have been ketoacidotic all day, every day, ever since he first noticed her deteriorating mental state in 2017?
It irked him to hear a psychiatrist dismiss her increasingly bizarre and dangerous decision-making as merely “idiosyncratic” and indicative of “a free spirit”.
“You didn’t know my mum!” Gary exclaimed when Dr Kamel made those comments.
There is a world of difference, Gary contends, between harmless eccentricity – somebody hanging all their paintings upside down or wearing a funny hat – and his mother, a once house-proud, sharp-minded paralegal, shambling around a house full of years-old dog faeces, gibbering about a plot to steal her land.
There remains no question in his mind that Rosslyn was mentally ill. While he understands the inquest is limited to the events that directly caused her death, he believes that limit facilitates a “cover-up”, where everybody avoids consequences for leaving his mother in squalor for years.
He can’t understand how the law can permit the state to break into someone’s home and remove their dogs from the appalling conditions, yet prevent the state from doing the same for their owner.
“There was ample evidence for everybody to get involved,” he maintained.
