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Adoo-Kissi-Debrah Inquest: Coroner recommends setting health-based legally-binding air quality limits to prevent future deaths from air pollution

London, 21 April 2021: The Coroner to the re-opened inquest into the death of Ella Adoo-Kissi-Debrah, has today issued a Prevention of Future Deaths (‘PFD’) report which expresses his concern about the lack of legally binding air quality targets, lack of public information and appropriate doctor training.

Philip Barlow, Assistant Coroner for South London, made the report following the Inquest into Ella’s death which concluded in December 2020 and resulted in the landmark ruling that “excessive levels of air pollution” were a causal factor in her death. The report will be sent to Government departments and other bodies.

The Coroner’s report identified three areas of specific concern (at Section 5 of his PFD Report) for which there is an ongoing risk to members of the public of illness and death from air pollution.

The first recommendation is aimed at the three government departments involved in the inquest (Defra, DfT and DHSC). The Coroner said that the Government needed to pay particular attention to reducing air pollution levels to concentrations safe for human health. The PFD report identifies as its first concern:

(1) “The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.”

This follows on from the Inquest conclusion in December 2020, in which the Coroner ruled that “the overwhelming conclusion … is the health risk caused by air pollution and the urgent need to improve air quality”. He also highlighted the need for “co-ordinated action” within the Government1 .

Key witnesses to the Inquest, including Dr Claire Holman and Professor Sir Stephen Holgate, had expressed the need for setting health-based targets for air pollution reduction.

Writing in his Reasons accompanying the PFD Report, Mr. Barlow voiced his “matters of concern” flowing directly from his conclusions at the inquest, most importantly “the undeniable health problems caused by not following the WHO guidelines in setting national air pollution targets, specifically on particulate matter”.

He said “[t]he discrepancy between national targets and WHO guidelines was central to the inquest and addressed by most of the witnesses.” Under existing law the permitted annual mean levels of PM10 are double those recommended by the WHO guidelines as the minimum requirements whereas for PM2.5 the UK legal limits are more than double the WHO guideline limits.

He continued: “There was no dispute that the level of particulate matter pollution continues to be a major issue of public health concern. The number of deaths associated with air pollution is extremely high… There is a very clear need for action to be taken to prevent the continuation of this circumstance.” 2

A second recommendation directed at Central Government Departments, the Mayor of London and the London Borough of Lewisham, relates to low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. The report states:

(2) “Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.”

Mr. Barlow’s accompanying comment was:
“I am concerned at the comparatively low level of access to public information, such as the UK-Air website. Leaving this as a local issue is clearly not resulting in people accessing relevant information, and it is therefore a concern that needs to be brought to the attention of central government.”

The evidence from the inquest revealed that there was a significant lack of information available to people regarding air pollution levels in their local area. The information that was provided was insufficiently publicised and had very few subscribers. Similarly, there was a lack of public awareness around the health risks associated with air pollution and a deficit of advice about steps that can be taken to minimise exposure to air pollution. Rosamund and other witnesses at the inquest stressed the need for improved public information.

The Coroner’s final concern is that “adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals”. Mr. Barlow identified three levels of professional organisations responsible for undergraduate and postgraduate education, as well as professional guidance who he recommends should address this failure.


  • a. “Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
  • b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
  • c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.”

He also sent the recommendation to the DHSC and Faculty of Public Health for information.

Mr. Barlow expanded on this in his logic statement with the following:

“Air pollution was not discussed as a possible causative factor [throughout Ella’s illness] even though Ella was seen by GPs and specialists in several specialist hospitals. It is an issue that needs to be raised with a large number of organisations responsible for medical education, which I have listed in the report.”

The evidence from the inquest revealed that despite Ella having very severe asthma, the cause of which was under investigation by medical specialists in several hospital air pollution was never considered and therefore Rosamund was not advised of steps that could have helped reduce Ella’s exposure.

This recommendation echoed his concern raised in the Coroner’s Conclusions in December 2020 when he said, “There was, therefore, an alarming disconnect between the message being sent out about the overall health effects of air pollution, including the number of deaths it causes, and the actual advice being given to patients and the public.”

These three recommendations point to a need for the Government and other public bodies to take a more health-focused approach to air pollution. Health should be prioritized in order to prevent future unnecessary deaths from air pollution.

Rosamund Kissi-Debrah, Ella’s mother, commented on the report:

“Children are dying unnecessarily because the Government is not doing enough to combat air pollution. In order to save lives the Government must act now and take the three steps that the Coroner has identified in his report. It’s crucial that the UK takes more forceful action to reduce pollution to safe levels – first and foremost, by complying with WHO air quality guidelines. I will be contacting George Eustace to ask him to make amendments to the Environment Bill to enshrine WHO limits and to achieve these in the shortest possible time. Health needs to be a major focus in combatting air pollution.

“I will also be asking the Secretary of State to ensure that there is a duty to inform the public and train the medical profession as the Coroner recommended. There needs to be improved public information about the levels of pollution that people are exposed to and the health risks. As the parent of a child suffering from severe asthma, I should have been given this information but this did not happen. Because of a lack of information I did not take the steps to reduce Ella’s exposure to air pollution that might have saved her life. I will always live with this regret. But it is not too late for other children. I invite the Government to act now to reduce air pollution. Immediately. Not in eighteen months, not in five years – that’s not fast enough. People are dying from air pollution each year. Action needs to be taken now or more people will simply continue to die.”

Jocelyn Cockburn of Hodge Jones & Allen, the family’s lawyer, said:

“Rosamund embarked on her legal journey in order to find out why Ella died. She achieved this in December when the Coroner handed down his conclusions. Today, she has reached another milestone in her legal journey. Because of Ella’s inquest there has been an investigation into current practices which continue to pose a danger to health and present a risk of future deaths. The Government should act to implement the Coroner’s three recommendations to protect life. This could be described as forming the basis of ‘Ella’s Law’.

“The coroner has made very clear, crucial recommendations surrounding WHO legal guidelines and the need to reduce air pollution to healthy levels. In order to prevent further unnecessary deaths the Government must re-look at the Environment Bill and commit to meeting WHO guideline levels of particulate matter*. Given that current levels are dangerous and pose a risk to life, steps should be taken to meet the WHO guideline levels in the shortest time possible.

“Despite knowledge at Government level for decades of the health risks posed by air pollution, shockingly – especially to vulnerable groups such as asthmatics – this knowledge has never been included in the training and education of medics. Therefore the medical profession has been woefully ill-equipped to advise patients about the risks and what they can do to avert them. Ella’s case is a stark example of this failure. She was treated by multiple specialists at various hospitals across London who were actively looking for the cause or trigger of Ella’s asthma so to save her life. It was a race against time. However, air pollution was never mentioned. This meant that Ella and her family could not take action – including moving house – which could have saved her life.

“Ella’s inquest has moved the debate on about air pollution. The inquest shows that the impact of air pollution on individuals can be examined and recorded. Looking at air pollution on a micro level can help promote a better understanding of the effects on society of breathing unhealthy air. It will strike a chord with parents throughout the country, but particularly those living in urban areas. The inclusion of Air Pollution as a cause of death of an individual is highly significant in terms of the pressure on the Government to act now.

“Air Pollution is causing the unnecessary deaths of children like Ella and until the Government take decisive action this will continue to happen”.

Guy Mitchell of Hodge Jones & Allen, a member of the family’s legal team, said:

“This report follows a ground-breaking finding that air pollution contributed to Ella’s death. The Coroner clearly expresses concern that further action is needed to prevent further deaths. It comes at a hugely significant moment, with the Environment Bill due to come back to Parliament. The Bill is currently deficient in not including health based air quality targets or requirements for provision of information to the public. The Government should act to ensure the Coroner’s concerns are addressed in the Bill”.

*Further comment from Jocelyn Cockburn on WHO guidelines and the Environment Bill:

“Unfortunately, the inquest showed that insufficient steps were taken to reduce air pollution in Ella’s lifetime. The Government was in breach of annual legal limits of Nitrogen Dioxide during the whole period of her illness and death and London remains in breach of legal limits of NO2. During Ella’s lifetime the UK did not, and still does not, meet the minimum requirement for levels of particulate matter as set out in the WHO guidelines. In his conclusions the Coroner referred to the levels of air pollution to which she was exposed as ‘excessive” and “very high”.

“The Coroner’s report is highly relevant to the debates in Parliament about amendments to the Environment Bill. Ella’s death shows the need for the Secretary of State to commit to meet the WHO limits. Unfortunately, the Bill currently falls far short of this, and in fact, contains few references at all to public health.

“Inexplicably, the Environment Bill contains no provisions about informing the public about air pollution. The Coroner’s second and third recommendations go to this point and also point to the need for the current Bill to be amended. People have a right to know about air pollution levels in their area and what the Government is doing to reduce pollution to healthier levels, and this should be included as an express provision in the Environment Bill. The public should be informed of the risks that air pollution pose to themselves and their families and also what steps they can take to mitigate exposure to air pollution. Also, tied in with the need to reduce air pollution levels, the public should be informed of the risks so they can reduce their own polluting behaviour.

“In making a PFD report on public information the Coroner is highlighting the risk to life that this failure poses.”

Notes to Editors:

N.B. The Coroner’s first recommendation relates to the need to set national limits for particulate matter which are in line with WHO Guidelines. He said in his reasons: “The concern I have raised is specific. It is focused on an important discrepancy between the national limits and the guidelines set on health grounds by the World Health Organization”.

There is not the same discrepancy as regards NO2 because current regulations for annual mean limits of NO2 are set at the same level as WHO guideline rates. Therefore, although the Government has been in breach of the legal limits of NO2, the fact that those limits exist and are legally binding means that there is currently no need for a recommendation on this.

However, it is important that the Government do retain existing regulations after the Environment Bill is enacted (as they have previously committed to do) as the removal of legally binding NO2 limits would inevitably give rise to a risk of future deaths.

Legal team
Rosamund was represented by:

  • Jocelyn Cockburn, Partner in the Civil Liberties and Human Rights team at Hodge Jones & Allen
  • Guy Mitchell, Civil Liberties and Human Rights solicitor at Hodge Jones & Allen
  • Megan Finnis, paralegal at Hodge Jones & Allen


  • Richard Hermer QC, Matrix Chambers
  • Adam Straw QC, Doughty Street Chambers
  • Ravi Mehta, Blackstone Chambers, of counsel.

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1 In the December conclusions, the Coroner pointed to the “very high” levels of Nitrogen Dioxide and particulate matter to which Ella was exposed, “both in excess of the World Health Organization guidelines”. The principal source of which was traffic pollution.

2 The inquest itself had examined the impact of air pollution exposure on Ella and the Coroner accepted expert evidence from Professor Stephen Holgate that “[a]ir pollution exposure was a significant contributory factor to both the induction and exacerbations of her asthma”. He also found that “excessive air pollution” contributed to her death.