The inquest last December into the death of nine-year-old Ella Adoo-Kissi-Debrah made waves around the world. The photograph of Ella, which was displayed in the coroner’s court and which the coroner described as showing Ella with a smile “as wide as the photograph”, beamed out from screens and newspapers internationally. As the family’s lawyers, we watched the evidence unfold over nine days. The culmination of years of tireless campaigning by Ella’s mother, Rosamund, had led to a landmark moment – the first time that air pollution had been officially recognised as a cause of death.
Last week, in his follow-up report, Phillip Barlow expressed concern that further action was needed to prevent future similar deaths. The coroner identified three areas of concern: the discrepancy between current national targets for particulate matter and those recommended by the World Health Organization; the lack of public awareness; and the insufficiency of communication by clinicians to patients of the risks of air pollution.
Although the UK was in breach of legal limits of nitrogen dioxide during Ella’s life (many areas remain in breach today), the UK’s annual legal limits themselves are in line with those recommended by the WHO. However, this is not the case for particulate matter, where the UK’s current legal limits are far below those recommended by the WHO. In relation to fine particlate matter, or PM2.5, the UK’s current annual limit is two and a half times above that recommended by the WHO, and at present there is no limit in relation to hourly levels. The coroner has recommended that this disparity be rectified and that the WHO limits should be seen as the minimum acceptable standard.
The inquest also identified that while Ella had been seen by multiple specialist clinicians, none had warned her mother of the risks of air pollution. It was only after her death that Rosamund became aware of the risk that air pollution posed. The coroner has identified public awareness and clinician training as an ongoing problem.
It is rare for coroners to be so bold in their recommendations. The urgency of the issues should be understood in the context of inaction by successive governments, which was exposed in the course of the inquest.
The inquest heard that government reports had rung the alarm on the risks and causes of air pollution many years before Ella was born. Most notably, in 1998, the Department of Health’s committee on the medical effects of air pollutants reported that air pollution contributed to tens of thousands of deaths each year. However, as the former chair of the committee Prof Stephen Holgate explained, it appeared that the body’s reports merely went to sit on government shelves.
In the face of these warnings, successive governments failed to respond. Rather, it was hoped that the next round of incoming European vehicle emission standards would solve the problem. Even if that approach had been effective, evidence presented by the government suggested it would have only been so at a lethally slow pace.
The inadequacy of this pace was recognised by the government in the 2007 air quality strategy. The strategy noted that without additional action, the UK would fail to reduce nitrogen dioxide levels below legal limits until more than a decade after they came into force in 2010. It proposed various policies to reduce air pollution – but not a single one was implemented.
In 2015, it became clear that motor manufacturers had been cheating the laboratory vehicle emission tests for diesel cars, and real-world emissions were far exceeding the emissions limits. However, as the Department for Transport’s witness, Bob Moran, accepted at the inquest, evidence of the unreliability of the laboratory tests was known from 2004 (the year Ella was born).
As expected, the UK exceeded the legal limits in relation to nitrogen dioxide when they came into force in 2010. That same year, Ella started to suffer terrifyingly severe asthma attacks. Finally, in February 2013, after about 30 of such attacks, Ella sadly died.
It took a little girl’s death and the exceptional courage of her mother to bring this issue to the public spotlight. Until now, the health effects of air pollution had been largely considered through epidemiological population-based data, rather than through the impact on individuals. Perhaps this has allowed governments to pay lip service to the “public health emergency” while failing to actually treat it as such. Now the human cost of air pollution has a face, and it is the poignantly beaming smile of a nine-year-old girl called Ella.
The coroner’s warnings come at a significant moment, with the environment bill due to come back to parliament. Before the bill was first published there was an expectation that it would include a legally binding target for PM2.5 in line with WHO guidelines. However, this did not prove to be the case, with the bill only committing to setting targets by the end of October 2022 and giving the secretary of state wide powers to revoke or lower targets.
Rosamund is adamant that lessons are learned from Ella’s death. She is asking the government to make changes to the environment bill that will protect public health. She wants the government to heed the coroner’s recommendations and set legally binding air-quality targets based on WHO guidelines and a duty to inform the public. These changes could be described as “Ella’s law”.
Although Ella’s death certificate is the first to recognise air pollution as a cause of death, it has actually caused thousands of deaths and continues to do so. The government’s response will speak volumes about how seriously it really takes air pollution. More inaction now, following the precedent of successive governments before it, will be fatal.
-
Jocelyn Cockburn is a partner in civil liberties and human rights, and Guy Mitchell is a solicitor in civil liberties and human rights, at Hodge Jones & Allen solicitors