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recurance

Ella Kissi-Debrah

20 Apr 2021 · Coroner Philip Barlow · Inner South London

The coroner's concerns

  1. 1. excessive particulate matter

    “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.”
  2. 2. lack of public awareness of air quality information

    “There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. 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”
  3. 3. inadequate communication of air pollution health risks to patients and carers

    “The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels: 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”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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