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“Extraordinary” Landmark Inquest Rules Air Pollution Contributed to Death of 9-Year-Old Ella Adoo-Kissi-Debrah

Global first as British girl’s death certificate lists air pollution as a cause of death

18 December 2020, London: In what is believed to be a global first, Deputy Coroner Phillip Barlow ruled on Wednesday that Ella Adoo-Kissi-Debrah, a 9 year-old girl who lived just 25m from the South Circular in South London, died in February 2013 as a direct result of air pollution.

Reading aloud his verdict, Philip Barlow said that he believed air pollution made a “material contribution to Ella’s death”. She was exposed to levels of nitrogen dioxide and particulate matter in excess of World Health Organisation guidelines. The level of air pollution she was exposed to was therefore excessive. The principal source of her exposure was traffic emissions.

He noted also that there was a “recognised failure to reduce the level of nitrogen dioxide to within the limits set by EU and domestic law, which possibly contributed to her death”. He added that Ella’s mother “was not given information about the health risks of air pollution and its potential to exacerbate asthma”. The lack of information also possibly contributed to her death.

The Coroner ruled that “Air Pollution was a significant contributory factor to both the induction and exacerbation of her asthma”

He concluded: “Ella died of asthma contributed to by exposure to excessive air pollution.”

The medical cause of death was listed as:

  • 1a) acute respiratory failure
  • 1b) severe asthma
  • 1c) air pollution exposure

Ella’s mother, Rosamund Adoo-Kissi-Debrah, said immediately after the verdict that she was in “absolute shock”.

“Up until the point when the coroner says his verdict, you’re not sure it will happen. And then in the moments afterwards, as it sinks in, you think about the amount of change it can bring to so many children. I thought about the children all around the world who this might help, because I receive letters from people as far away as India about the problems they face with air pollution. It’s going to take a while for me and my family to absorb this news; it’s been such a journey to get to this point.”

She added:
“We’ve got the justice for Ella which she so deserved, but there are still illegal levels of air pollution now, as we speak, so this matter is far from over. What I would like to see happen as a result of this inquest is better education about air pollution and for more serious steps to reduce pollution to safe levels. We talk about working toward cleaner air in eighteen months or several years’ time, but that’s not fast enough. I would like to see a public awareness campaign undertaken. There needs to be clear and concise information, so people can understand it. I still think there’s a lack of understanding about the damage it does to young lungs, especially.”

Rosamund’s lead lawyer at Hodge Jones & Allen, Jocelyn Cockburn said:

“When Rosamund came to see me nearly 5 years ago she was determined to find out why Ella died and I am so pleased for her and her children that she now has the answer to that important question. I am sure she will take time to absorb the Coroner’s detailed reasoning but his conclusion is clear – that excessive levels of air pollution caused her death.

“It has been a long legal journey and throughout we have been met with scepticism that it is possible to link air pollution to an individual death. I have always found this reticence surprising given the universal acknowledgement that air pollution causes tens of thousands of deaths in the UK every year. This case has broken through that mindset.

“Because of this ruling air pollution can no longer be ignored and overlooked as a factor that has a real impact on individual human beings, especially the vulnerable. The two week investigation into what happened to Ella brings the air pollution debate right down to the micro-level. I was shocked to learn that air pollution had never been examined in a coroner’s inquest before or listed as a cause of death. I now expect that air pollution will be examined in the context of other deaths.

“In terms of raising awareness of air pollution, this case has told the human story behind the statistics and makes it much more difficult for the authorities to ignore the call to clean up our air. That is Ella’s legacy. ”

“I would like to pay tribute to Rosamund and her family for the determination they’ve shown in bringing Ella’s story and such a public health issue to the fore at great personal cost. I don’t think I’ve met anyone stronger than Rosamund and I am proud to have worked with her for so many years”.

Guy Mitchell, a solicitor in Rosamund’s legal team at law firm Hodge Jones & Allen said: “Ella was exposed to very high levels of air pollution, over and above the WHO health guidelines, and we think there will be pressure building for the UK Government to adopt those guideline levels so that the population is not exposed to very high levels of air pollution.

“There has been a lot of interest in this case from around the world. Air pollution is a global issue and there is the real hope that this will have a far-reaching effect. The scale of the inquest and the detail that the coroner went into was mandated by Article 2 of the European Human Rights Act, Right To Life, which sets a precedent for other lawyers in other jurisdictions to use Article 2 in this way to protect lives from environmental danger.”

The coroner has stated that he will accept submissions from the Interested Parties on the issue of a Prevention of Future Death report. Submissions must be received by 15 January 2021 which the Coroner will consider.

The coroner closed the inquest on Wednesday by describing Ella as “someone with bright, brown eyes, and a smile that seems even larger than the photograph [we’ve seen of her].” He thanked Rosamund “for the determination you’ve shown in getting us here.”

Further information

  • The ruling followed a ten-day inquest held between 30 November and 11 December, where Mr. Barlow heard key evidence from Professor Sir Stephen Holgate who explained that it was the cumulative impact of toxic air that affected Ella. Professor Holgate told the court that Ella had a rare form of asthma which meant she experienced a prolonged life-threatening mode, and ‘lived on a knife-edge’. Even a small event could have triggered an episode and led to a hospital admission, of which Ella suffered 28 in the space of just 3 years. It was for this reason that Professor Holgate described Ella as a ‘canary in a coalmine’;

Rosamund was represented by Hodge Jones & Allen:

  • Jocelyn Cockburn, partner in the Civil Liberties and Human Rights team
  • Guy Mitchell, solicitor
  • Megan Finnis, paralegal


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

Jocelyn paid tribute to the legal team, saying:

“I feel privileged to have worked with such a committed legal team, there are others not listed here who have also previously worked with dedication towards this outcome. In particular I would like to recognise the mammoth efforts of the counsel team, Richard, Adam and Ravi, as well as Guy at Hodge Jones & Allen who often worked long hours into the night to achieve the best outcome for Ella”.

A chronology of Rosamund’s legal battle to get justice for Ella can be seen below.

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Georgina Whittle
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Notes to Editors:


15 February 2013
Ella Adoo-Kissi-Debrah died of a severe asthma attack following nearly 3 years of seizures and over 30 hospital admissions associated with her asthma. She was 9 years old.

24 January 2014
Rosamund establishes the Ella Roberta Foundation in honour of what would have been Ella’s 10th birthday.

26 September 2014
First Inquest into Ella’s death takes place at Southwark Coroner’s court before Assistant Coroner, Phillip Barlow. The cause of death was recorded as Acute Respiratory failure caused by severe asthma. The first inquest into her death did not investigate the role of air pollution.

2015 /2016
Air Pollution came to prominence through reporting about the Dieselgate scandal, in which it was revealed a number of car manufacturers had installed ‘defeat devices’ to mask emissions levels in official tests. The ClientEarth Supreme Court ruling which ordered the UK government to reduce pollution levels to within lawful limits. Sadiq Khan becoming London Mayor and raising the profile of air pollution and the publication of a groundbreaking report by the Royal College of Physicians (authors including Professors Holgate and Grigg) setting out the ‘dangerous impact of air pollution on the nation’s health’.

Rosamund had begun campaigning and speaking about air pollution during this period and became increasingly concerned that air pollution may explain Ella’s death.

Independently, Jocelyn Cockburn, in her work as a human rights lawyer was exploring the possibility of launching legal action against the government on behalf of those whose health was impacted by air pollution. Jocelyn herself was affected, having a restricted lung capacity and asthma. Jocelyn was forced to leave London in 2018 because of the impact of air pollution on her health.

May 2016
Rosamund seeks legal advice from Jocelyn at Hodge Jones & Allen following concerns that Ella’s health may have been affected by air pollution and her concerns about the impact of air pollution on her other children. Different legal options are considered and preparatory work is carried out to analyse the levels of air pollution that Ella was exposed to, obtain evidence from Rosamund about Ella’s life and health and to obtain expert evidence.

July 2018
Rosamund and her lawyers apply to the Attorney General to reopen the inquest into Ella’s death following new evidence from a report from Professor Stephen Holgate on air pollution.

August 2018
London Mayor, Sadiq Khan, adds his support to the call to quash the first inquest. Rosamund delivers a 100,000 petition to the Attorney General.

February 2019
Rosamund and her lawyers apply to the high court to quash the findings of the first inquest.

2 May 2019
High Court judges quash the findings of the first Inquest due to new evidence about the risks of air pollution following evidence submitted suggesting that air pollution contributed to her death. The court rules that it is necessary in the interests of justice for a fresh inquest into Ella’s death to be held.

30 November – 11 December 2020
Second Inquest into Ella’s death, investigating the role of air pollution in Ella’s death.

16 December 2020
Conclusions delivered by Deputy Coroner Phillip Barlow ruling that air pollution made a “material contribution” to Ella’s death.