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Following a landmark ruling in December 2020, H.M. Assistant Coroner for Inner South London, Philip Barlow, today issued a Report to Prevent Future Deaths (PFD), following the inquest into the death of Ella Adoo-Kissi-Debrah. In a legal first, the Coroner had concluded that “air pollution exposure” was a cause of Ella’s death.

The PFD Report constitutes a further notable development of the law with the Coroner concluding that “there is a risk that future deaths could occur unless action is taken”. The Coroner has urged 14 individual institutions, including central government departments, to implement changes to prevent further lives being endangered.

The Coroner’s “Matters of Concern” were as follows:

1.    The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The Coroner recommended that legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.

2.    There is a low public awareness of the sources of information about national and local pollution levels. The Coroner has called on national as well as local government to better publicise this information and ensure it is “sufficiently detailed”. He also concluded that “this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors”.

3.    The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The Coroner concluded that this needed to be addressed through changes to undergraduate and postgraduate training, as well as professional guidance.

The institutions have been given until 17 June 2021 to respond. Their responses must contain “details of action taken or proposed to be taken, setting out the timetable for action” or an explanation as to why no action is proposed.

The UK’s breaches of air quality legislation have given rise to three sets of proceedings (summaries can be found herehere and here) by the NGO, ClientEarth, which resulted in Court orders quashing the national Air Quality Plans and requiring urgent corrective action.

Ravi Mehta acted on behalf of the Family at the Inquest, led by Richard Hermer QC and alongside Adam Straw, instructed by Hodge Jones & Allen, and previously acted for ClientEarth in their second and third claim.

The Report to Prevent Future Deaths is available here.