Ella Kissi-Debrah

Mr Philip Barlow 
Assistant Coroner 
London Inner South Coroner’s Court 
1 Tennis Street 
London SE1 1YD 

10 June 2021 

Dear Mr Barlow, 

By email 

Coroner’s Report to Prevent Future deaths: Regulation 28  

Thank you for your email of 21 April 2021 and the attached Regulation 28 Report to prevent future 
deaths, in which you request a response from the British Thoracic Society (BTS) in relation to the 
details of actions that have been taken, or which are proposed to be taken, in relation to Concern 
3: The adverse effects of air pollution on health are not being sufficiently communicated to patients 
and their carers by medical and nursing professionals.  

Firstly, we would like to acknowledge that this Report was prepared as a result of the tragic death 
of a child. We would like to express our sadness for the loss of such a young life and send our 
condolences to Ella’s mother and the wider family. 

The death of 9-year old Ella is a grim reminder of the effects of air pollution and how serious the 
consequences of not tackling air pollution can be. While this tragic death was linked to asthma, air 
pollution affects people with many other respiratory diseases too, so this issue widely impacts our 
patients.  We strongly support the Report’s recommendation for the government to set legally 
binding  targets  for  PM2.5  based  on  WHO  guidelines  to  reduce  the  deleterious  effects  of  air 
pollution in the UK. 

We  wish  to  assure  you  of  the  Society’s  commitment  to  contributing  to  the  development  of 
evidence-based guidance in this area, and to continuing to make available clear information for 
health care professionals to use in their interactions with patients and their carers.   

In relation to the activities of the Society, I can provide the following summary of work to date and 
future plans. 

Clinical guidelines 

BTS is a multi-professional society which aims to improve the standards of care for those with 
respiratory disease and whose work influences and informs doctors, nurses and all the other 
professionals with whom these patients come into contact.   
BTS, in partnership with the Scottish Intercollegiate Guideline Network (SIGN), has produced the 
British Guideline for the Management of Asthma over a number of years, the most recent edition 
being published in 2019.   

/continued 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The 2019 edition of the BTS/SIGN Guideline states that “Increased asthma symptoms in young 
children (mean age ≤9) have been linked, in observational studies, to exposure to air pollutants, 
including particulates, nitrogen dioxide, sulphur dioxide and ozone” (para 6.2.4: 
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ ). BTS and SIGN are 
now working in partnership with the National Institute for Health and Care Excellence (NICE) to 
produce a joint guideline on the management of asthma.  Work will begin on the new joint 
guideline later in 2021, the scope of which will include reference to environmental factors 
including air pollution and with a planned publication date in 2023.  

2 

Information provision 

BTS has included a focus on the effect of air pollution and other environmental and occupational 
factors on lung health in its comprehensive programme of scientific and clinical conferences and 
courses over a number of years.  Most recent examples include: 

-  A keynote lecture by Professor 
the 2017 Summer Meeting. 
Short courses for health care professionals in relation to Occupational and 
Environmental Lung Disease in 2018 and 2021. 

- 

 “The need for a new clean air act” at 

-  Regular scientific symposia and discussions at the annual BTS Winter Meeting including: 
2018: Poster discussion session on Triggering and controlling asthma exacerbations 
2019: The BTS Grand Challenge Lecture: Health Impacts of Air Pollution (
Munich) 
2020: Discussion session: The evidence for and against low emission zones. 

, 

In addition, BTS provides regular scientific and clinical input to the development of information 
produced by NICE via the stakeholder consultation process, most notably in relation to guidance 
on indoor and outdoor air pollution. 

It is of prime importance that health care professionals are aware of resources that can be used 
to inform patients and carers, and the BTS partner website “Respiratory Futures” provides 
signposting to resources on air pollution and respiratory health.   

The Taskforce for Lung Health, of which BTS is a member, explicitly highlights air quality as an 
issue for those living with lung disease: https://www.blf.org.uk/taskforce/plan/prevention    

Future plans 

BTS strongly supports the communication of the effects of air pollution by health care 
professionals to patients and carers. We intend to build upon the work undertaken to date in the 
following ways over the coming year: 

- 

-  By continuing to raise awareness of the effects of poor air quality on lung health through 
the evidence-based guidance we produce, the conferences and short courses we run and 
the provision of expertise to stakeholders; 
Through the production of an updated Position Statement on air quality and lung health 
which builds upon the 2020 position statement which noted that: 
Air pollution resulting from road transport, namely nitrogen dioxide and particulate 
matter, is of particularly urgent concern in relation to climate change and respiratory 
health. 

/continued 

BTS 10 June 2021 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 -  By adding the health care profession voice to the debate on climate change and air 
pollution through our membership of the UK Health Alliance on Climate Change and 
through our continued involvement in the Taskforce for Lung Health. 

3 

Finally, it is important to note that while health care professionals are able to provide advice to 
patients, their carers and in the case of children, parents, on actions that can be taken to 
mitigate against the effects of air pollution, they are not able to address the root cause of poor 
air quality.  

The Society will do all it can to inform, educate and support respiratory health care professionals 
in this area, but we wish to emphasise that the risk of air pollution to public health will only be 
significantly reduced if government and other policy makers act in order to regulate pollution 
generating activity.  

We wholeheartedly support the findings of the Coroner in this case and we hope that it will bring 
about action from the government on this issue.  

Yours sincerely, 

Dr 
BTS Honorary Secretary 

BTS 10 June 2021 

3

Dr Phillip Barlow 
Assistant Coroner 
Southward Coroner’s Court 
1 Tennis Street 
London 
SE1 1YD 

17 June 2021 

Dear Sir 

Litigation Group 
102 Petty France 
Westminster 
London 
SW1H 9GL 

T  020 7210 3000 

DX 123243, Westminster 12  www.gov.uk/gld 

Your ref: 
Our ref: 

Inquest 

Inquest touching the death of Ella Adoo Kissi-Debrah 

Response to Regulation 28 Report 

1.  This letter  is  sent on behalf of the Department  for  the Environment,  Food and  Rural Affairs 

(“Defra”), the Department for Transport (“DfT”) and the Department for Health and Social Care 

(“DHSC”) in response to the Regulation 28 Report to Prevent Future Deaths, and accompanying 

reasons of 20 April 2021 (“the Report”). The Central Government Departments are referred to 

collectively as “the CGDs”. 

2.  In providing this response to the Coroner’s Report, the CGDs wish to repeat the offering of their 

sincere condolences to Ella’s family, and emphasise their commitment to addressing the matters 

of concern raised by the Coroner.  

3.  The Report arises from the re-opened Inquest into the death of Ella Adoo Kissi-Debrah (“Ella”) 

on 15 February 2013. The conclusion at the end of the Inquest was that Ella died of asthma, with 

air pollution being a significant contributory factor to both the induction and exacerbation of her 

asthma. The matters of concern identified in the Report were that:  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a)  National limits of Particulate Matter are set at a level far higher than guidelines set by 

the World Health Organisation (“WHO”). This concern was addressed to the CGDs. 

b)  There is a low public awareness of the sources of information about national and local 

pollution levels. This concern was addressed to the CGDs, the Mayor of London and the 

London Borough of Lewisham.   

c)  The adverse effects of air pollution on health are not being sufficiently communicated to 

patients  and  their  carers  by  medical  and  nursing  professionals.  This  concern  was 

addressed  to  a  number  of  named  professional  organisations,  and  sent  to  DHSC  for 

information. 

4.  Accordingly, the CGDs focus on addressing concerns 1 and 2. In the event that you would be 

assisted by any further information from the CGDs, in relation to any of the concerns, the CGDs 

will of course seek to obtain and provide the requested information. 

Concern 1:  Review of National Limits for Particulate Matter 

5.  The CGDs note the Coroner’s concern that the UK’s current national limits for particulate matter 

concentrations are higher than the guidelines set by the WHO. The CGDs accept that there is 

more work to be done at the national level to reduce overall concentrations of particulate matter.  

The Environment Bill currently making its way through Parliament will make provision for the 

introduction  of  a)  an  annual  mean  concentration  target  for  PM2.5  in  ambient  air;  and  b)  a 

population  exposure  reduction  target  for  PM2.5.  An  extensive  public  consultation  is  being 

planned to take place over the course of the next year.  

The Current Position 

6.  Following  the  United  Kingdom’s  departure  from  the  European  Union,  the  limit  values 

established  under  the  Air  Quality  Standards  Regulations  2010  (S.I.2010/1001  (“the 

Regulations”) continue to apply.    

7.  The emission limits  set out in the Regulations are: 

a)  PM10: -  

i.  A 24 hour daily mean of 50 μg/m3 not to be exceeded more than 35 times per 

year. 

ii.  An annual mean average of 40μg/m3. 

- 2 - 

 
 
 
 
 
 
 b)  PM2.5: - an annual mean of 25 μg/m3 was to be met by 1 January 2015. This was amended 
by regulation 2 of SI 2020/1313 to 20 μg/m3 which was to be achieved by 2020 as well 

as a 15% national exposure reduction target set between 2010 and 2020  (See Schedules 

2 and 7 to the Regulations). Both of the targets have been met.  

8.  These limits have, since 1 January 2005, formed national objectives set under the Air Quality 

(England) Regulations 2000 (SI 2000/928) and the Air Quality Standards Regulations 2010 (SI 

2010/1001)  

9.  Whilst there is no doubt that at a national level air pollution has reduced significantly since 2010 

– emissions of fine particulate matter have fallen by 11%, while emissions of nitrogen oxides 

have fallen by 32% and are at their lowest level since records began, equally there is no doubt 
that there is more to do.1  

The WHO Guidelines 

10. The WHO published Air Quality Guidelines for Particulate Matter, ozone, nitrogen dioxide and 

sulphur dioxide in its publication Global Update 2005 [22/7511 to 7622] (“the 2005 update”). 

In addition to “air quality guideline values”, this document contains interim targets for various 

pollutants  and  identifies  incremental  steps  en  route  to  progressive  reduction  in  areas  where 

pollution is high (supra at page 8). 

11. In terms of air quality guidelines (“AQG”) the 2005 update explains (see page 7): - 

The WHO air quality guidelines (AQGs) are intended for worldwide use but have been 

developed to support actions to achieve air quality that protects public health in different 

contexts. Air quality standards, on the other hand, are set by each country to protect the 

public health of their citizens and as such are an important component of national risk 

1 To this end Government has put in place a £3.8 billion plan to improve air quality and cleaner transport, which 
includes: 

1.  £1.5 billion in funding to support charge point infrastructure and grants to support uptake of ultra-low 

emissions vehicles, which has now risen to £3.5 billion following subsequent funding announcements; 

2.  Since then, the Prime Minister has launched ambitious plans to boost walking and cycling in England, 
with a vision that half of all journeys in  towns and cities are cycled or walked by 2030. This includes a 
£2 billion package of funding for active travel over 5 years;  

3.  £880 million to help local authorities develop and implement local air quality plans and to support those 

impacted by these plans.  

In addition, Defra is continuing to drive forward the actions outlined in the Clean Air Strategy, and has passed 
legislation to phase out the sale of house coal and small volumes of wet wood for domestic burning which came 
into force on 1 May 2021, with a particular view to tackling PM2.5 pollution 

- 3 - 

 
 
 
 
 
 
                                                      
 management and environmental policies. National standards will vary according to the 

approach  adopted  for  balancing  health  risks,  technological  feasibility,  economic 

considerations and various other political and social factors, which in turn will depend 

on, among other things, the level of development and national capability in air quality 

management.  The  guideline  values  recommended  by  WHO  acknowledge 

this 

heterogeneity  and,  in  particular,  recognize  that  when  formulating  policy  targets, 

governments should consider their own local circumstances carefully before adopting 

the guidelines directly as legally based standards. 

12. The 2005 update therefore makes it clear that the AQG should not be regarded as standards in 

themselves, but rather as guidelines to be considered in the context of prevailing exposure levels 

and environmental, social, economic and cultural conditions (see also:  Evaluation of the WHO 
air quality guidelines: past, present and future (2017)2) at p29: - 

It  has  repeatedly  been  stressed  that  the  guidelines  are  not  intended  to  be  taken  as 

recommendations  for  air  quality  standards  per  se,  but  rather  as  a  rigorous  scientific   

tool   that   can   be   used   by regulatory authorities as a basis for setting standards, 

taking      into      account  local  socio  political  and  economic  conditions  and  prevailing 

ambient  concentrations  of  air  pollutants.    Cost–benefit  analysis  of  various  pollution 

reduction options is an increasingly common tool supporting development of air quality 

policies. The evaluation of evidence provided by the WHO guideline process, and not 

only the numerical guidelines, is an essential input to such analysis. 

13. The AQGs developed in relation to: - 

a)  PM10 (also described in the guide as “coarse particulate matter”) identify a figure of 20 

μg/m3.    

b)  PM2.5 identify a figure of 10 μg/m3. 

14. As recognised in the 2005 update the extent to which reductions in small particle concentrations 

to or below the guideline levels recommended by the WHO are technically feasible will vary 

from country to country and will depend on local circumstances.  

2https://www.euro.who.int/__data/assets/pdf_file/0019/331660/Evolution-air-quality.pdf 

- 4 - 

 
 
 
 
 
                                                      
 15. To  illustrate  the  extent  of  this  variation  by  reference  to  the  United  Kingdom,  the  highest 
background PM2.5 concentrations across the UK (modelled in 20193) was 14.8 μg/m3 and the 

lowest  2.4  μg/m3.  These  variations  arise  in  part  from  natural  sources  and  transboundary 

contributions to concentration levels of small particles, which in South East England is around 

7 to 8 μg/m3, whereas in the north of England it is around 4 to 6 μg/m3.4  

16. Additional  factors  that  influence  the  background  concentration  include  season  and  weather 

conditions. At times, depending on wind direction and other circumstances, around a third of 

the background concentration level  of small particles in  the  United  Kingdom (up  to 50% on 

specific days) are from sources outside of the UK (for example, from continental Europe)5.  On 

top  of  this  are  the  anthropogenic  contributions  from  UK  sources,  which  vary  from  region  to 

region but in major urban areas are in the range of 3-6 μg/m3 above the rural background. The 

impact of local sources increases concentrations further, for example alongside busy roads there 

is generally a 1-2 μg/m3 increment on top of the urban background. 

17. As a result of these factors, the concentrations of small particles that people inhale at a particular 

place  are  composed  of  primary  emissions  from  natural  and  anthropogenic  sources,  and  the 

resuspension of particles from activity in the local area. A locally produced spike of particulate 

pollution, will add to a background level comprising particulates that have blown in from other 

areas  within  the  UK  (Regional  Sources,  such  as  the  South  East,  North  West  of  England)  or 

transboundary  sources  such  as  continental  Europe,  depending  on  the  prevailing  weather 

conditions.6  

3 https://uk-air.defra.gov.uk/data/pcm-data: Graph from Clean Air Strategy showing background levels across 
the country 
4https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770715/clea
n-air-strategy-2019.pdf (page 29): “The concentration gradients from north to south and east to west across the 
country are shown in the graph there contained, taken from the 2019 Clean Air Strategy, which shows the natural 
components (for example from sea salt and rural dust) and transboundary emissions (distant sources).  Emissions 
from the United Kingdom adding to this: local sources, for example from nearby roads or domestic burning, but 
neighbouring towns and industry also have an impact. Secondary PM2.5, generated by chemical reactions in the 
atmosphere between other types of pollutants, can be a result of emissions in other parts of the country, carried 
by the wind.” 
5 The sources from continental Europe are similar to those that generate anthropogenic emissions in the UK and 
include  agricultural  activity,  industrial  activity,  domestic  burning  and  transport.  The  concentrations  that 
accumulate as a result of these emissions reaching the UK depend on the prevalent wind directions, meteorology 
and scale of the source activity, combined with rate of atmospheric process. If the wind direction is from Eastern 
Europe  then  downwind emissions  are influenced  by  coal  burning  industrial activity.  From  central  or  western 
Europe the sources are predominantly agricultural but can include emissions from industrial activity from the 
Rhine and other industrial areas. 
6 Some of these particulates form as a result the chemical conversion of other pollutants e.g. ammonia released 
from  agricultural  sources  and  are  known  as  secondary  particulates.    The  chemical  mix,  diversity,  and 
concentration of pollutants changes continually, dependent on the pollutants being emitted locally, emitted from 

- 5 - 

 
 
                                                      
 18. Returning to the 2005 update, the report also acknowledges that the feasibility and social and 

economic costs of the steps which need to be taken to achieve particular levels of reduction in 

air pollution must be weighed against the degree to which the reduction improves the level of 

health protection. In this regard, there can be no doubt that to achieve reductions in small particle 

pollutant  concentrations  in  a  large  and  densely  populated  city  such  as  London,  significant 

interventions  and  controls  need  to  be  implemented.  The  sheer  number  of  different  activities 

involving friction or combustion (which generate PM2.5 emissions)7 that need to be carried out 

on a daily basis, in a confined area such as London, inevitably impacts on what is feasible – both 

technically  and  socio-economically.  Furthermore,  even  where  steps  are  taken  to  address  one 

source  of  pollutant,  there  remain  others  in  relation  to  which  technically  a  solution  is  not  yet 

available. As such, given this multitude of different sources of pollutants there are no easy or 

quick fixes to deliver significant reductions of particulate concentrations, particularly in densely 

populated urban environments.  

19. The 2005 update recognises that inevitably there will be local areas with characteristics which 

pose particular challenges in seeking to achieve reductions in air pollution at p 8: 

Air pollution levels may be higher in the vicinity of specific sources of air pollution, such 

as roads, power plants and large stationary sources, and so protection of populations 

living in such situations may require special measures to bring the pollution levels to 

below the guideline values.  

20. Lastly under this heading, turning to interim targets, the 2005 update identifies the following: - 

a)  For PM10, interim targets of 70 μg/m3, 50μg/m3  and 30μg/m3. 
b)  For PM2.5, interim targets 35μg/m3  25 μg/m3 and 15 μg/m3 . 

The Clean Air Strategy, the Environment Bill 2020 and a greater focus on WHO guidelines   

21. In accordance with the objectives underpinning the 2019 Clear Air Strategy, the Government 
has committed through clauses 1 and 2 of the Environment Bill8 to setting: - (1) an annual mean 

concentration target for PM2.5 in ambient air, and (2) at least one further long-term air quality 

target which we propose will be a PM2.5  population exposure reduction target.  

sources considerable distances away, and changing weather conditions that influence the dynamic chemistry in 
the atmosphere, and how the pollutants are dispersed. 
7 For example, trains, buses, planes, construction and road works, heating homes and business premises. 
8 The Environment Bill is currently undergoing passage through the House of Lords:  

- 6 - 

 
 
 
 
 
 
                                                      
 22. The concentration target will be set for all areas of the country, regardless of current exposure. 

Since publishing the Clean Air Strategy, we have used the World Health Organisation guidelines 

on PM2.5 to inform our ambition in shaping these targets. In respect of concentration targets on 

19 August 2020 Defra published a target framework: Environment Bill - environmental targets.  
This included the following proposal with respect to PM2.5 9: 

By introducing a new concentration-based target we will improve the ‘minimum’ level 

of air quality across the country. We have considered the progress our actions to meet 

our emission reduction commitments will deliver in terms of reducing PM2.5 levels across 

the country and how levels will compare to WHO guideline levels. This was outlined in 

our evidence paper published in July 2019. The work stated that whilst it was technically 

feasible to reach WHO guidelines levels, additional action will be needed in order to 

reduce  levels towards  WHO guideline levels  most  notably  in London  and  other large 

urban areas. Professor 

 (Chair of the Air Quality Expert Group in the UK) 

outlined during committee stage of the Environment Bill that it may not be possible to 

reach  those  levels  everywhere.  More  work  is  required  in  order  to  establish  what  an 

ambitious but achievable target should be (setting a level and a date for achievement). 

Whilst a new concentration ‘threshold’ target will be challenging to meet in certain parts 

of the country (especially in densely populated urban areas), it will not drive action to 

improve air quality in parts of the country which already achieve the threshold value. 

Such  a  target  will  also  not  drive  action  once  that  threshold  level  has  been  achieved. 

Therefore, a concentration ‘threshold’ target alone is unlikely to result in the greatest 

public health benefit. To put it in context, Public Health England estimate that just a 

1μg/m3 reduction in PM2.5 concentrations could prevent 50,000 new cases of coronary 

heart disease and 9,000 new cases of asthma by 2035. 

23. It was in view of the latter concerns that, in addition to the concentration target, consideration 

was to be given to introducing a target aimed at reducing average population exposure to PM2.5 

across England, with a view to driving continuous improvement across all areas of the country 

in order to maximise the public health benefit. As was recognised, population exposure targets 

9https://www.gov.uk/government/publications/environment-bill-2020/august-2020-environment-bill-
environmental-targets 

- 7 - 

 
 
 
                                                      
 are  complex  and  more  work  was  needed  to  develop  a  viable  methodology  for  achieving  the 
reduction targets.10 

24. The  exposure  reduction  target  will  be  developed  to  drive  reductions  not  just  in  pollution 

“hotspots”,  but  in  all  areas,  with  corresponding  long-term  health  benefits.  As  with  the 

concentration target, exposure reduction targets will be set having regard to scientific advice that 

there is no “safe threshold” for PM2.5 below which there are no negative health impacts, and to 

the feasibility and economic cost of the various alternative steps that are technically available to 

implement. 

25. Further to considering the World Health Organisation guidelines and the advice of a wide range 

of independent experts in shaping both targets, the Government will commit that the new Office 

for Health Promotion, working across Government, will consider as a priority how public health 

benefits can be achieved through reductions in population exposure to PM2.5 via an action plan, 

taking into account the particular circumstances experienced in London and the South East. 

26. The  setting  of  the  targets  will  be  informed  by  iterative  engagement  with  key  umbrella 

organisations  throughout  the  target  setting  process,  together  with  consultation  with  key 

stakeholders who will be invited to provide written responses on proposed targets within each 

priority  area,  in  order  to  obtain  views  on  the  ambition,  evidence  and  achievability  of  target 

proposals.  

27. An  Impact  Assessment  will accompany  the  consultation and consider the environmental  and 

socio-economic considerations associated with each target.  

28. In addition, the Secretary of State is required (Clause 7 and 8 of the Bill) to prepare: -  (i) an 

environmental improvement plan setting out the steps the Government intends to take to improve 

the natural environment in the period to which the plan relates, and (ii) annual reports setting 

10 Independent technical advice for the development of air quality targets is provided to Defra by the Air Quality 
Expert Group (AQEG), together with the Committee on the Medical Effects of Air Pollutants (COMEAP).  
At the request of Defra, AQEG sought input from the wider research community on future PM2.5 concentrations 
in England via a Call for Evidence. This information received will be used to provide context and interpretation 
of model runs conducted specifically to inform target setting. 
The AQEG is undertaking a further review of all evidence to produce a summary synthesis, which will form part 
of  the  supporting  evidence  to  accompany  the  public  consultation  on  air  quality  targets.  That  report,  and  all 
contributions received will be published on the UK-AIR website. 
In  addition  to  independent  expert  advice,  Defra  is  utilising  a  wide-ranging  consortium  of  leading  air  quality 
experts and organisations to develop the evidence to inform targets and provide this to the AQEG and COMEAP 
so that their advice can best inform the analysis undertaken.  These organisations include Wood Plc, Ricardo EE, 
Imperial College London, the Centre for Ecology and Hydrology and Econometrics Research and Consulting. 

- 8 - 

 
 
 
 
 
                                                      
 out the progress made in implementing the steps identified in the environmental improvement 

plan and in achieving any targets set under clause 1 and 2 of the Bill.   

29. Defra recognises that the total mass of particulates, of varying chemical composition and origin, 

requires action to be taken in relation to many sources of pollution.  By way of example, whilst 

undoubtedly of significant benefit, it is unlikely  that measures targeting traffic and domestic 

combustion alone will achieve the necessary reductions in PM2.5 concentrations in areas such as 

London  to  meet the reduction targets. As the expert evidence heard during the  course of the 

Inquest makes clear, spikes in pollution levels can be driven by factors beyond direct national 

control.  In  particular,  transboundary  pollution  episodes  of  PM2.5  in  South  East  England  and 

London often derive from continental Europe (and on occasions further afield) in consequence 

of wind and weather conditions (see, for example the episode evidenced on day 3 of the Inquest). 

30. Defra also recognises that it is unrealistic to expect technology alone to provide solutions in the 

short term, and that the cost involved in achieving substantial reductions in air pollution will 

require  society  and  businesses  to  accept  significant  changes  to  activities  such  as  travel  and 

heating.  For  example,  to  achieve  concentration  reductions  close  to  the  WHO  guideline,  we 

would  need  to  consider  implementing  measures  such  as  banning  all  domestic  combustion  of 

solid fuels and reducing the numbers of vehicles of all types in urban areas, requiring tougher 

standards for equipment and operations at construction sites.  Commercial cooking and BBQs 

are also potent sources of particulate matter and might require controls. 

31. This,  in  turn,  will  require  further  steps  to  be  taken  to  inform  the  awareness  of  society  and 

business  of  the  adverse  impact  of  air  pollution,  so  as  to  render  acceptable  the  impact  of  the 

changes that will need to be made. It is for this reason that, in committing to set ambitious targets, 

it is proposed that a full public consultation take place, supported by evidence about the adverse 

impact  of  air  pollution,  achievability,  interventions  required,  costs  and  expected  benefits  to 

public health.  

32. In  the  context  of  achievability  and  intervention  required,  the  consultation  process  will  also 

address the following technical considerations: 

a)  A review of the present nationwide and transboundary sources of PM2.5, and how they 

contribute to local pollution levels; 

b)  Measures  to  be  implemented  to  achieve  progress/  a  reduction  in  PM2.5,  and  where 

additional/supplementary monitoring may be required in order to do so; 

- 9 - 

 
 
 
 
 c)  The extent to which technological innovations within a range of sectors, and behavioural 

changes may occur, or be encouraged, to reduce concentrations. 

33. It is envisaged that the consultation will begin in early 2022 and the aim is for the Statutory 

Instruments setting targets to be laid by October 2022. 

34. In setting new targets through the Environment Bill, there is also a commitment to significantly 

enhancing the monitoring network, with a view to capturing population wide exposure, as well 

as supplemental monitoring in order to enhance its ability to assess progress and evaluate the 

effectiveness of policy interventions. The work to design an expanded monitoring framework is 

to be undertaken alongside the ascertainment of targets set out above. 

35. As part of this process, in 2018/19 Defra commissioned the Environment Agency to carry out a 

strategic review of the monitoring network, including external engagement with end users and 

experts. It has secured £1M for this year (2021/2022) and initiated an expansion of particulates 

monitoring networks. Defra has also funded research and development and practical pilot studies 

into the use of new low-cost sensor technology (£2m over the last two years). In order to identify 

suitable  technical  standards  for  measurement  of  accuracy  and  other  performance  parameters 

(which  is  currently  a  significant  barrier  for  the  use  of  low-cost  sensor  technology),  Defra  is 

working with the British Standards Institute and the National Physics Laboratory and intends to 

commission the development of a Publicly Available Specification in the Summer.  

Concern 2 – Public Awareness of Sources of Information about Air Quality 

36. The CGDs share the Coroner’s concern that, whilst a range of information on air quality is made 

available to the public, and promoted through a range of programmes run by local government, 

national government and broadcasters, there is a need to: - (i) increase public awareness of the 

existence of this information, and (ii) further enhance how this information is presented, to make 

it as accessible and useful as possible. 

37. The main current resource for air quality information is UK-AIR.  Defra provides air quality 

information  online,  via  its  UK  Air  Information  Resource  website  (UK-AIR),  at  http://uk-

air.defra.gov.uk/. On UK-AIR, individuals can access:  

a)  Forecasts: Defra provides forecasts to give advanced warning of the expected 

levels  of  air  pollution  for  the  UK.  Information  is  updated  daily  early  in  the 

morning and provides forecasts for today, tomorrow and the following 3 days. 

- 10 - 

 
 
 
 
 
 
 UK Forecast maps can be searched by place name or postcode to give a more 

detailed local view. The 5-day forecast for a person’s favourite location can be 

saved and presented above the maps.  

b)  Latest Pollution Summary: This shows current measured levels of air pollution 

and provides a retrospective view of pollution levels for 16 regions of the UK. 

c)  Information  on  how  air  quality  is  monitored  and  modelled  in  the  UK,  and 

where the monitoring sites are located. This includes an interactive map showing 

details of monitoring sites so users of the site can locate monitors of interest, for 
example sites near their home, and view data on pollution levels for these sites11. 

d)  Around 80% of automatic data from air quality monitoring networks managed 

by the majority of local authorities: Users are able to access the local automatic 

data in the same way they can Defra’s national data, for example using the data 

download service or looking at site locations on  a network map.  To  facilitate 

locally  managed  data  sharing  with  UK-AIR  further,  a  dedicated  API  for  this 

service has been established. This new service brings together national and local 

data sources, which have historically been managed and published separately, to 

one place, and  enables interested parties  (the public, researchers, industry  and 

NGOs) to rapidly review locally managed monitoring. 

38. Defra has recognised that the current size and complexity of the UK-AIR site makes information 

difficult  to  access.    Defra  has  provided  funds  to  the  charity  “Global  Action  Plan” 

(https://www.globalactionplan.org.uk/business-for-clean-air-taskforce) to help fund a Clean Air 

Hub website. This website brings together information on what air pollution is, how it affects 

health, what actions can be taken to protect individuals and others. It also contains downloadable 

resources and news stories on clean air issues. The charity is further responsible for the “Clean 

Air Day” air pollution campaign.   

11 The following additional information, principally of interest to experts, is provided: 

i.  Historical and near-real time data from the UK’s national networks of air pollution monitoring sites 
can be downloaded from the UK-AIR data archive. Data from the oldest automatic monitoring sites go 
back to 1972, and there are data going back to 1961 from sites using simpler nonautomatic monitoring 
techniques. This resource enables users to explore and understand how air pollution has changed over 
time and current pollution levels their areas. 
ii.  The UK Air Quality Data Catalogue is a searchable catalogue of UK air quality monitoring, modelling 
and emissions datasets. For example, it identifies what data are available, who the responsible owner is 
and where to find the datasets.  
iii.  Information on science and research into air pollution. The UK-AIR library provides a comprehensive 
resource of the latest scientific and policy documents related to air pollution in the UK. 

- 11 - 

 
 
                                                      
 39. Local  Authorities  (“LAs”)  receive  air  quality  information  from  Defra  through  a  variety  of 

means,  and  a  range  of  communication  materials  have  been  developed  for  LAs  to  use  in  the 

implementation of their Clean Air Zone programmes and (alongside Public Health England).   A 
‘directors  of  public  health’  toolkit,  has  also  been  developed12  which  provides  a  briefing  and 

guidance  to  Directors  of  Public  Health  on  how  best  to  communicate  matters  relating  to  Air 

Quality. A number of Local Authorities also provide their own Air Quality messaging services 
to vulnerable groups (e.g. through SMS and email alerts e.g. AirAlert13).  

40. Several national broadcasters provide Air Quality information. The BBC displays an assessment 
of air pollution alongside pollen and UV14. Apple provide Air Quality information as part of 

their weather app. In addition, Defra has been assisting ITV in considering what information it 

might provide as part of the ITV weather forecast and have held training sessions on Air Quality 

for ITV staff.  

41. Defra’s User Needs research15 has highlighted that those searching for air quality information 

can often find it complex and difficult to interpret.The CDGs are committed to improving the 

provision of air quality data and information. In order to do this, the following actions are being 

taken forward: 

a)  Defra is undertaking a fundamental review of the UK-AIR website to improve the 

functionality and user experience. This project will identify a structure for 

disseminating information on air quality that reflects the needs and preferences of the 

key user groups and stakeholders that use the site. This work will be based upon user 

needs research and will start with immediate effect, with the initial “discovery phase” 

completing early next year. 

b)  A fundamental component of communicating information on UK-AIR is the Daily Air 

Quality Index (DAQI), which gives advice, based on the level of pollution that is being 

forecast  and  measured.  Evidence  about its development  was provided  at  the  inquest.  

Defra, Public Health England and DHSC are working with the chairs of the Air Quality 

Expert  Group  (AQEG)  and  the  Committee  on  Medical  Effects  of  Air  Pollutants 

(COMEAP) to establish an expert group to steer the overhaul and update the DAQI in 

the light of accumulated new evidence and experience.   

12 https://laqm.defra.gov.uk/assets/63091defraairqualityguide9web.pdf 
13 https://airalert.info/Splash.aspx 
14 https://www.bbc.co.uk/weather/sw1p 
15 Defra, UK - Science Search 

- 12 - 

 
 
 
 
                                                      
 c)   An updated DAQI could enable more specific messaging for different population groups 

and pollutant levels.  This will assist health professions in advising patients when poor 

air quality is forecast. We will work with the health professions and media organisations, 

including  weather  forecasters  to  test  the  DAQI  and  how  it  can  be  most  effectively 

communicated and consider the effectiveness of SMS alerts  

d)  This  year,  Defra  is  increasing  the  amount  of  Air  Quality  Grant  funding  available  for 

Local Authorities to £8million.  We will invite specific proposals to use a proportion of 

this funding to enhance local air quality information and awareness, encouraging local 

health networks to work collaboratively with Local Authorities to pilot more effective 

methods of public engagement.  

e)  Defra will continue to engage with broadcasters, local radio stations, social media 

companies, and other media outlets, to look at ways to improve communication on air 

quality. More broadly, the government will continue to work with a range of 

stakeholders and partners, including Global Action Plan, Asthma UK and the  British 

Lung Foundation Partnership, or British Heart Foundation and weather forecasters to 

provide clear messages about the risks of air pollution and the actions people can take. 

42. From  a  health  perspective,  NHS  England  and  Improvement’s  (NHSEI)  Children  and  Young 

People’s (CYP) Transformation Programme is working to increase awareness by promoting a 

systematic  approach  to  asthma  management  which  includes  a  comprehensive  education 

programme,  identifying  environmental  triggers,  promoting  personalised  care,  effective 

preventative medicine and improved accuracy of diagnosis. This includes a National Bundle of 

Care  (“The  Bundle”),  a  set  of  National  Standards  with  associated  Integrated  Care  System 

deliverables.  The  Bundle  is  developed  with  clinical  and  patient  experts,  Royal  Colleges, 

Professional Bodies and the third sector, to provide a framework for Local Systems to lead work 

on a range of improvements to support Children and Young People with asthma. Phase one of 

the Bundle will be published end June 2021, with Phase two published by April 2022. 

43. The Bundle will set out evidence-based interventions to help children, young people, families 

and carers to control and reduce the risk of asthma attacks and to prevent avoidable harm. A 

bundle  developed  for  this  covers  each  of  the  following  components  based  on  the  patient 

pathway: 

a)  Environmental Impacts 

- 13 - 

 
 
 
 
 
 b)  Accurate and Early Diagnosis 

c)  Effective Preventative Medicine 

d)  Managing Exacerbations 

e)  Severe Asthma 

44. The 2015 Directors of Public Health Air Quality toolkit is a project funded by Defra to encourage 

Directors of Public Health to become local champions for air quality improvement in their local 

areas.  The  toolkit  contains  information  and  material  to  help  DPHs  to,  among  other  things, 

communicate the health impacts of air pollution to the general public and promote behavioural 

change in the community where necessary.16   

Concern 3 – Communications to patients and their carers by medical and nursing professionals. 

45. There is a degree of overlap between concerns 2 and 3. The dispersal of information regarding 

air  pollution,  and  potential  health  impacts,  including  via  the  resources  described  above  in 

response to concern 2 could be enhanced by the assistance of health care professionals, given 

the levels of trust the public have for these professionals.   

46. The CGDs have noted with interest the recommendations in concern 3 made by the Coroner 

with  respect  to  addressing  awareness  within  the  medical  and  other  health  care  professions 

themselves of air pollution issues, at undergraduate, postgraduate and professional development 

levels. 

47. There is clearly a link between such awareness raising, so as to improve communications to the 

patients and their carers, and the efforts of CGDs and local authorities to raise public awareness 

of  the  sources  of  information  available.  For  this  reason,  Defra  and  DHSC  are  assisting  the 

professional  organisations  to  take  forward  activities  to  further  engage  their  membership  in 

understanding air pollution and communicating information to patients and the wider public. 

48. By way of an example of the collaborative work being undertaken, the Chief Medical Officer 

for  England,  as  part  of  the  ongoing  dialogue  with  the  medical  profession,  recently  hosted  a 

roundtable on 1 June with the organisations and professional bodies referenced in relation to 

concern  3.  This  meeting  focused  on  the  on-going  cross-organisation  cooperation  to  agree 

concrete improvements in the way health care professionals communicate the adverse effects of 

air pollution on health with patients and their carers.  

16 http://randd.defra.gov.uk/Default.aspx?Module=More&Location=None&ProjectID=18580 

- 14 - 

 
 
 
 
 
 
                                                      
 49. Another example of the work being undertaken is a Defra funded pilot project, conducted by

Global Action Plan and the UK Health Alliance on Climate Change, investigating whether and

how respiratory physicians and paediatricians could be trained to better deliver air quality advice

to their patients, and act as champions for air quality within their places of work. Defra are keen

to  build  on  this  work  and  are  planning  further  work  with  general  practitioners  providing  air

quality advice and information to a range of vulnerable groups.

50. The CGDs recognise the important role of the medical profession in raising awareness of the

availability and relevance of the Air Quality Information available, and will continue to: -

a) Make Defra, DHSC and PHE’s expertise and experience in regard to air quality issues

available to the relevant professional organisations, and allow them access to extensive

domestic and international network of air quality academics and experts; and

b) Assist,  wherever  possible,  with  the  development  and  implementation  of  activities

undertaken to engage the medical profession in communicating the adverse effects of air

pollution.

Conclusion 

51. The CGDs hope that the matters set out above address in sufficient detail the concerns raised in

the Report. If, however, further information or clarification would be of assistance the CGDs

will of course endeavour to provide the same.

Yours sincerely 

Government Legal Department 

On behalf of the Central Government Departments 

- 15 -

14 June 2021 

Mr Philip Barlow 
Assistant coroner 
London Inner South Coroner’s Court 

Dear Mr Barlow 

Regulation 28: Report to Prevent Future Deaths – Ella Adoo Kissi-Debrah 

I was very sorry to hear of the tragic circumstances of Ella Adoo Kissi-Debrah’s death. I 
extend my sincere condolences to Ella’s family and to other families affected. 

You raise three concerns in your report, the last of which should be addressed by the 
named organisations. As the Medical Director and Director of Education and Standards at 
the General Medical Council, I am able to respond to both 3a (undergraduate medical 
education) and 3b (postgraduate medical education).  

I note that Ella’s death occurred in February 2013. Since that time, we have made 
significant changes to our standards and guidance relating to the education and training of 
doctors. I will first summarise the role of the GMC as a regulator and then explain how it 
relates now to the education and training of doctors around air pollution exposure and 
related environmental issues. 

Our role as a medical regulator 

Our powers in medical education, as set out in the Medical Act 1983, are in three parts: 
firstly, we set the outcomes for graduates of UK medical schools leading to entry on to the 
medical register; secondly, we approve the curricula for postgraduate training of doctors; 
and thirdly, we quality assure all aspects of medical training against our standards for the 
management and delivery of medical education and training. The principle of patient 
safety drives our work. 

Medical education must adapt to the needs of society and be appropriately responsive to 
patients and the public. We regularly review our guidance and educational outcomes to 
make sure they keep up to date with new information and developments in healthcare and 
reflect changing patient needs.  

  
 
 
 
 
 Undergraduate education 

We determine and publish the high-level outcomes all medical students are required to 
demonstrate in order to graduate. We updated our Outcomes for graduates in 2018 after 
extensive consultation. This is supplemented by a set of core Practical skills and 
procedures graduates must have achieved when they start work for the first time so they 
can practise safely. The content map which underpins the forthcoming Medical Licensing 
Assessment (explained in more detail later) is based on these outcomes and practical 
procedures.  

Our powers don’t extend to mandating specific content in undergraduate curricula, but the 
outcomes do describe relevant key themes around the environmental factors contributing 
to health. These include requiring newly qualified doctors to: 

  recognise signs of environmental exposure 

  evaluate environmental factors which influence health and disease in different 

populations 

  evaluate related hazards in ill-health with ways to mitigate effects. 

We decide which organisations can award a UK primary medical qualification, and an 
organisation looking to establish a new medical school is subject to a multi-stage process 
of quality assurance and accreditation to ensure they can deliver a programme that 
delivers the Outcomes for graduates and meets the standards set out in Promoting 
excellence: standards for medical education and training.  

Foundation Programme 

All doctors enter the two-year Foundation Programme after graduating from medical 
school. It provides new graduates with a range of essential interpersonal and clinical skills 
for managing acute and long-term conditions. The Academy of Medical Royal Colleges 
(AoMRC) develops the Foundation Programme curriculum, which describes the outcomes 
all Foundation doctors should demonstrate on completion of the programme. We approve 
the curriculum. The current curriculum includes a requirement to recognise the impact of 
wider determinants of health and advise patients on preventative measures. A new 
curriculum has been approved for implementation from August 2021 and includes a 
specific section on health promotion and public health as a specific area of core learning.  

The Foundation programme curriculum requires first year trainees to meet the outcomes 
we have set out in Outcomes for provisionally registered doctors with a license to practise, 
which includes fifteen core clinical and procedural skills. This enables the trainee to apply 
to the GMC for full registration and a license to practice, which is a requirement of entry to 
the second year of the Foundation Programme. 

 
 Specialty training 

The curricula for postgraduate specialty training are set by individual medical royal 
colleges and faculties. In 2017 we published revised standards for curricula - Excellence by 
design - which requires curricula to be mapped against our Generic professional 
capabilities framework of shared generic and specialty-specific outcomes. The framework 
sets the essential capabilities which underpin professional medical practice and are a 
fundamental part of all postgraduate training programmes. The capabilities include a 
section on understanding health inequalities and health promotion, which is required of all 
doctors in training. Most royal colleges and faculties have now reviewed their specialty 
curricula against our revised standards.  

Quality assurance of education and training 

We also have a duty to make sure medical education and training in the UK is meeting our 
standards. We expect organisations responsible for educating and training medical 
students and doctors in the UK to meet the standards set out in Promoting excellence: 
standards for medical education and training.   

We quality assure medical schools, postgraduate deaneries and their local offices, and 
local education providers (such as trusts and health boards) to check they are meeting our 
standards. Our quality activities are risk based, which means we look at our evidence and 
decide which areas are likely to be of concern. We provide feedback to organisations on 
areas of good practice and can take action if they are not meeting our standards. 

More information on how we quality assure can be found on our website. 

Our response to this report to prevent future deaths 

In the report, you raise the concern that the adverse effects of air pollution on health are 
not being sufficiently communicated to patients and their carers by medical and nursing 
professionals.  

The adverse effects of air pollution are a public health matter which goes beyond the 
health service and affects society as a whole. Our approach to regulating medical 
education is underpinned by the principles of the World Health Organisation, health 
depends on the three interlinked factors of physical, mental, and social wellbeing. Every 
human being has a fundamental right to enjoy the highest attainable standard of health 
without distinction of race, religion, political belief, economic or social condition.  

The revisions to our Outcomes for graduates and the introduction of the generic 
professional capabilities framework have enhanced the focus on health promotion, illness 
prevention and addressing health inequalities. 

The following section sets out our requirements and expectations for communication with 
patients, all of which has been revised since Ella’s death in February 2013. To clarify, the 
GMC’s role is to approve curricula and set standards of practice - we are not responsible 

 
 for deciding what information is given to patients. I will also outline work we are doing to 
improve standards of practise and patient safety. 

Guidance on communication with patients 

In Good medical practice, our core guidance for all registered doctors, we stipulate that 
doctors ‘must give patients the information they want or need to know in a way they can 
understand’ (para 32). They must also ‘work in partnership with patients, sharing with 
them the information they will need to make decisions about their care’ (para 49), and 
‘support patients in caring for themselves to empower them to improve and maintain their 
health’ (para 51).  

And in Outcomes for graduates we say that newly qualified doctors from UK medical 
schools ‘must be able to communicate effectively, openly and honestly with patients, their 
relatives, carers or other advocates, and with colleagues (para 10). They also ‘must be 
able to work collaboratively with patients, their relatives, carers or other advocates to 
make clinical judgements and decisions based on a holistic assessment of the patient and 
their needs, priorities and concerns, and appreciating the importance of the links between 
pathophysiological, psychological, spiritual, religious, social and cultural factors for each 
individual.’ (para 14).  

However, this is not a comment on whether the doctor(s) in this case followed the 
guidance sufficiently well.  

Introduction of Medical Licensing Assessment 

To keep driving improvement, we’re introducing a new way of assessing medical students, 
as well as international medical graduates, that will ensure they meet a common and 
consistent threshold for safe practice before they’re licensed to work in the UK. The 
Medical Licensing Assessment will be based on a comprehensive content map which sets 
out the range of skills and knowledge that students will be required to have and could be 
tested on. It concentrates on the professional skills, knowledge and behaviours that are 
essential for safe practice. It also includes social and population health, and the list of 
practical procedures includes conditions related to this.  

All students graduating from UK medical schools from the academic year 2024/25 will 
need to pass the new assessment, which will also replace our current test for international 
medical graduates in early 2024. 

Shared learning across postgraduate specialties 

We are working with the Academy of Medical Royal Colleges (AoMRC) on the details for a 
process to identify and develop areas where key learning can be shared in postgraduate 
training across the various specialties and subspecialties. The aim of this will be to ensure 
high standards in core clinical areas. The process to identify and develop shared learning 
across specialties will consider post-qualification development as part of a programme of 
lifelong learning across a doctor’s career. We expect this work will begin later in 2021. 

 
 We will explore with the AoMRC whether the themes raised (environmental impacts/social 
inequality/health promotion) could be areas where key transferable content, knowledge 
and skills could be shared across postgraduate specialties. 

Credentialing 

We are introducing GMC credentials to formally recognise a doctor's expertise in a specific 
area of practice. Our aim is to approve credentials in areas of practice where they will help 
reduce risks to patients and support the service to provide better patient care. These 
credentials will be developed and delivered by other bodies, but approved, quality 
assured, and recognised by the GMC.  

Health Education England (HEE) are currently developing a system for identifying and 
supporting the development of multi-professional and uni-professional credentials, which may 
be England-wide or UK-wide. HEE have confirmed that they will add the theme of 
environmental impacts/social inequality/health promotion to the list as a potentially 
important area to consider as they progress the credentialing agenda. 

Lifelong learning 

Our Corporate Strategy 2021-25 commits to looking at making training for the medical 
workforce more flexible, throughout their careers – ‘The medical workforce has access to 
and capacity for lifelong learning to ensure they continually develop their skills for better 
patient care’.  

We are looking at how we can be more proactive in supporting doctors’ lifelong learning 
and continued professional development, which currently is done mostly through high 
level guidance and advice or targeted interventions such as Welcome to UK practice 
workshops.   

Final reflections 

I welcome the publication of this Prevention of Future Deaths report as an important 
measure to raise awareness of the impact of exposure to excessive air pollution with those 
who can take action to prevent future deaths.  

The GMC is committed to work with others in the health and care sectors to improve 
training of the professionals we regulate so that environmental factors contributing to ill 
health, are better recognised and treated. We have agreed to share our response with 
Professor 
England) and all the organisations who attended a multi-agency meeting hosted by Dr 

 (Chief Nursing Officer for 

 (Chief Medical Officer), 

 on 1 June 2021. We are pleased to note that in our conversations with others 
across the system, there seems to be a real desire to address these issues holistically, and 
that will require cooperation across numerous areas of government, the health service, 
regulators and the public at large. 

 
 
 Yours sincerely 

Professor 
Medical Director and Director of Education and Standards

BY EMAIL: 

Philip Barlow 
HM Assistant Coroner 
Inner South London 

Department of Education and Quality  
2nd Floor 
Stewart House 
Russell Square 
London 
WC1B 5DN 

11th June 2021 

Dear Sir, 

Ella Adoo Kissi-Debrah – Regulation 28 Report 

I write in response to your report of 20th April 2021 made under the Coroners (Investigations) 
Regulations 2013 (“the Regulations”). Please may I start by offering my sincere condolences to Miss 
Adoo Kissi-Debrah’s family following her tragic death from asthma contributed to by exposure to 
excessive air pollution.  

Your report raises concerns regarding medical and nursing professionals’ communication of the 
adverse effects of air pollution on health to patients and their carers. We note your report states that 
these concerns need to be addressed at both undergraduate and postgraduate education levels.  

To respond to your concerns, I will clarify Health Education England (HEE)’s role and responsibilities 
in the education and training of the medical and nursing workforce. I will also highlight interventions 
that HEE is taking to address healthcare professionals’ awareness of the health impacts of air 
pollution.  

HEE is a non-departmental public body accountable to the Secretary of State and Parliament. We are 
part of the NHS and work with partners to plan, recruit, educate and train the health workforce. We 
serve the people of England by educating, training and developing healthcare professionals. We 
support undergraduate and postgraduate health education and training for around 240,000 students 
and trainees across 350 different roles, including doctors, nurses, midwives, paramedics, healthcare 
scientists, pharmacists, and physiotherapists. We also provide planning, transformation and 
development support to the NHS workforce, for now and the future. 

Undergraduate medical and nursing education 

The standards for medical and nursing education in the UK are set by the respective independent 
professional regulator, the General Medical Council (GMC) and Nursing & Midwifery Council (NMC). 

Each individual medical school and university sets its own undergraduate curriculum, which must 
meet the standards set by the GMC and NMC, who then monitor and check to make sure that these 
standards are maintained.   

HEE funds clinical placements for undergraduate doctors and pre-registration nursing students in 
England. We set our expectations for the quality of the educational environment in our multi-
professional Quality Framework. The overarching objective of the Framework is to promote inter-
professional learning and to support and facilitate service transformation that meets current and future 
patient needs. 

 
 
 
 
 
 
 Postgraduate medical education 

The curricula for postgraduate specialty training are set by individual medical Royal Colleges and 
faculties, and the GMC approves curricula and assessment systems for each training programme. 
The Academy Foundation Programme Committee coordinates and facilitates the work of the medical 
Royal Colleges and faculties to produce the curriculum for the Foundation Programme, the first two 
years of postgraduate medical training.  

HEE commissions postgraduate medical education and training places in England. We set our 
expectations for the quality of the educational environment in our multi-professional Quality 
Framework. Our Postgraduate Deans and Foundation School Directors manage the quality of 
postgraduate medical education and work with employers to design training programmes that equip 
doctors with the skills they need to provide high-quality patient care.  

HEE continues to deliver a number of medical education reform proposals to improve the efficacy and 
flexibility of our medical education system. Building upon the findings of the Future Doctor 
engagement programme, HEE are working with stakeholders and partners to develop a wraparound 
professional development offer in postgraduate medical training to enhance the generalist skills of 
doctors. By embedding generalism in training, we aim to better equip doctors to understand and 
address the population health and care needs of the communities they serve, including to recognise 
and evaluate the environmental determinants of health. 

Postgraduate nursing education 

HEE supports the Continual Professional Development (CPD) of Nurses, Midwives and Allied Health 
Professions (AHP) in post-registration practice, within acute, mental health, community and primary 
care settings. An individual practitioner’s professional development should align to their specialist or 
generalist field of practice and be considered alongside the priority care pathways/areas of the 
Integrated Care System (ICS) or local trust, these being identified at a regular developmental review. 
Given the number of specialist practitioners across the domains of Nursing, Midwifery and AHP, 
environmental determinants are generally addressed at this stage in their educational and career 
development with a number of specialist courses supporting the CPD agenda.  

*********************** 

In response to Concern 3 raised in your report, HEE will write to the relevant medical Royal Colleges, 
GMC and NMC to highlight that improving awareness of the impact of air pollution on health should 
be considered when developing curricula. 

I hope that this response provides you with clarity of HEE’s role and responsibilities in the education 
and training of the medical and nursing workforce and gives you the assurance that HEE is committed 
to taking the learning from the tragic death of Ella Adoo Kissi-Debrah.  

Yours sincerely, 

Professor 
National Director of Education & Quality and Medical Director

Dr Philip Barlow 
Assistant Coroner 
London Inner South Coroner’s Court 
1 Tennis Street 
London  
SE1 1YD 

Chief Executive  
London Borough of Lewisham 
Laurence House 
Catford 
London SE6 4RU 

17th June 2021 

Dear Dr Barlow  

On behalf of the London Borough of Lewisham, I would like to extend our condolences 
once again to the family of Ella, our thoughts remain with all of those affected by her 
tragic death. The inquest into this was a watershed moment for many in public service - 
from  the  highest  levels  of  Government,  to  the  Mayor  of  London  and  Greater London 
Authority (GLA), all the way down to the local authority level. The Inquest itself drew to 
the attention of the country, through fair and accurate media reporting, the health risks 
of air pollution. Mrs Adoo Kissi-Debrah, a resident of our Borough, has been a dignified, 
passionate and powerful voice for change and we are confident that all those involved 
in air quality, public health and health education have learnt important lessons as a result 
of the Inquest and its conclusions.  

You have asked the London Borough of Lewisham to address one of three matters of 
concern that were raised in your Prevention of Future Deaths Report, focusing on public 
awareness of the sources of information about national and local pollution levels.  The 
London Borough of Lewisham notes that in your reasons you observed that: “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”. 
We agree with and support this observation. However, we are determined to do what 
we  can  at  a  local  level  to  improve  awareness  for  our  residents  and  hopefully  set  in 
process a domino effect which may lead to improvements in neighbouring Boroughs, 
across London and nationally.  

With this in mind, I can confirm that the key actions that we have and are taking on the 
issue of public awareness are as follows: 

  An expansion of monitoring capacity: at the time of Ella’s tragic death there 
were diffusion tubes monitoring NO2 levels at 47 sites and 4 automatic monitoring 
stations  measuring,  variously  NO2,  PM10  and  SO2  levels.  The  most  significant 
addition  shortly  after  Ella’s  death  was  the  creation  of  the  Honor  Oak  Park 
‘supersite’  automatic  monitoring  station  which  opened  on  1  January  2019  and 
which  monitors  PM10  and  PM2.5.  Further,  by  the  end  of  2020  the  number  of 
diffusion tube sites more than doubled to 106. Since the Inquest, capacity has 
grown even further and we are introducing important new technology as we are 

 
 
 
 
 
 
 
 
 
 
 
           
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 in  the  process of adding  several new  monitors to  monitor  PM2.5, particularly  in 
areas of high traffic. Due to technological advances, the measurement of PM2.5 
no  longer  requires  a  large  automatic  monitoring  station  and  more  flexible 
monitors can now be placed around the Borough. These will feed into a London 
wide  network  of  sensors  providing  greater  data  and  coverage  and  will  help  to 
contribute to improved public awareness of air pollution levels across the capital. 
We are also in the process of adding yet more diffusion tubes, with up to another 
75 monitors in total (both diffusion tubes and the new PM2.5 monitors) planned for 
installation by October this year. 

  WHO-specific  reporting:  Like  the  Coroner  and  Ella’s  family  (and,  we 
understand,  the  Mayor  of  London),  we  are  concerned  about  the  discrepancy 
between the national limits which are set by central Government and the WHO 
guidelines.  Whilst  we  understand  that  central  Government  has  been  asked  to 
address  this  as  a  separate  concern,  as  part  of  our  commitment  to  provide 
additional  and  meaningful  information  around  air  quality  levels,  the  London 
Borough of Lewisham will commit to identifying the WHO recommended levels 
alongside the current UK limits when publishing air quality data. We hope that 
this draws to greater public attention the difference between the limits, acts as a 
catalyst for other local authorities to do the same, and puts pressure on central 
government to take a more ambitious approach to limit values. This change in 
reporting will commence in documents and communication from 1st July 2021.   

  Raising awareness: As the London Borough of Lewisham highlighted during the 
Inquest, the raising of awareness of air quality issues has improved significantly 
since Ella’s death.  This  is partly  as a  result of  the  transfer  of  the public health 
functions from the NHS to the Borough in April 2013, which led to a Joint Strategic 
Needs Assessment for Air Quality in 2018, which will be refreshed again in 2022 
(and  which  has  a  target  audience  of  those  who  commission,  provide  or  use 
health,  social or children’s services  in  Lewisham).  It  has  also  improved  due  to 
technology and social media, so that the London Borough of Lewisham is able to 
promote airTEXT, the Imperial College London Air webpage, the GLA air quality 
web page/alerts, and even its own air quality App. However, there is more work 
that can and will be done. Our Head of Communications is currently formulating 
a plan which will include a multi-media approach: promoting air quality monitoring 
tools via social media and local advertising; ensuring information about air quality 
is positioned prominently on the London Borough of Lewisham and South East 
London  Clinical  Commissioning  Group’s  websites;  and  sharing  information  via 
social media and our residents’ newsletter for Clean Air Day on 17 June 2021. 

Finally,  the London Borough of Lewisham will  continue to  work collaboratively  and  in 
partnership with the GLA, other local authorities and organisations who are committed 
to  raising  awareness  of  air  quality  issues.  The  important  collaboration  with  the  GLA 
includes  ‘Breathe  London’  which  the  Mayor  of  London  has  agreed  to  support  until 
2024. We have recently been in close discussion with counterparts at the GLA and are 
eager to support their important work in this field.  

 
 
 
 
 
 
 
  
 
 
 
 I  trust  that  the  above  has  provided  an  insight  into  work  that  has  been  and  is  being 
undertaken to improve public awareness of the sources of information about national 
and  local  pollution  levels.  The  London  Borough  of  Lewisham  remains  committed  to 
continuing to raise these important issues, and maintain this essential dialogue and to 
see  what  else  can  be  done  at  a  local  level  to  help  address  this national,  and  global, 
concern.  

Yours sincerely,  

Chief Executive 
London Borough of Lewisham

Dr Philip Barlow 
Assistant Coroner 
London Inner South Coroner’s Court 
C/o 

Date: 16 June 2021 

Dear Dr Barlow, 

Inquest arising from the death of Ella Adoo-Kissi-Debrah 

I welcome your Report to Prevent Future Deaths (PFD) dated 20 April 2021 following the inquest 
arising from the death of Ella Adoo-Kissi-Debrah.  

I would like to take this opportunity to offer my sincere condolences to Ella’s family and friends.  

I am fully committed to addressing the areas of concern raised in your report and will continue to 
do everything in my power to ensure that all Londoners are aware of the dangers of air pollution, 
what they may do to help manage their exposure and, ultimately, can breathe clean air.  

There are three areas of concern raised in your PFD report. The second area of concern is 
addressed to the Central Government departments, the Mayor of London and the London Borough 
of Lewisham: 

‘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, for example by increasing the number of air quality sensors.’ 

I outline below my response to your second area of concern and also make some brief observations 
on the other two areas of concern raised in the report that are addressed to other organisations. 

I have made tackling air pollution a priority, embedding it across my strategies for London, 
including my Transport, Environment and Health Inequalities Strategies and the London Plan, and 
identifying it as a priority in the London Health and Care Vision. This informed my decision to 
implement ambitious measures such as the early introduction of the world’s first Ultra Low 
Emission Zone (ULEZ) in central London in April 2019, its forthcoming expansion up to the North 
and South Circular Roads this October and the introduction of tougher standards for heavy vehicles 
operating in the existing Londonwide Low Emission Zone (LEZ), enforced from 1 March 2021. 

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 My policies have contributed to an acceleration in improvement in air quality, with a 97 per cent 
reduction in the number of London state schools located in areas exceeding legal pollution limits 
and initial estimates of a 94 per cent reduction in the number of Londoners living in areas 
exceeding legal limits for nitrogen dioxide (NO2) between 2016 and 2019. Since 2016, the scale of 
reduction in NO2 has been five times greater in central London than the national average, but I 
know there is still more to do.  

Second area of concern – Public awareness of sources of information about national and 
local pollution levels 

As noted above, this second area of concern is addressed, amongst others, to the Mayor of 
London. There are a number of policies and tools we use to help raise awareness of sources of 
information about local pollution levels. 

Air Quality Alerts 

Raising awareness about air pollution has been a major priority for me. In 2016, I instituted an 
alerts system to warn Londoners about air pollution episodes. During high and very high air 
pollution days, air quality alerts are displayed at: 

o  2,500 bus countdown signs and river pier signs across London 
o  140 road-side dot matrix message signs on the busiest main roads into London, with 

instructions to switch engines off when stationary to reduce emissions 

o  Electronic update signs in the entrances of all 270 London Underground stations 

During moderate, high and very high alerts, the alerts system directly emails over 3,000 school 
contacts informing them of the potential pollution episode and provides a link to more information. 
Schools are also provided with details of the London Schools Pollution Helpdesk, which I launched 
in February 2021 in partnership with Global Action Plan and Impact on Urban Health to provide 
further support to schools in helping reduce staff and student exposure to pollution. During these 
episodes, we also send a direct email to the London boroughs and encourage them to share the 
alert with their relevant stakeholders.   

Additionally, during a high or very high alert, the NHS, Public Health England (PHE) and the 
London Fire Brigade are contacted via the London Resilience Forum to cascade to their networks. 
We use social media channels to make people aware of moderate air quality episodes as well as for 
high and very high alerts. We also work with London’s councils to promote the free airTEXT service, 
which provides borough-specific air quality alerts for local residents. 29 of the London boroughs 
actively fund the network, though alerts are provided for all London boroughs. A number of 
boroughs have also developed local air quality alerts apps.  

However, I appreciate that some of the most vulnerable Londoners may not be aware of the alerts 
which is why my officers are currently undertaking a review of my Londonwide alerts system, 
including message testing and exploring additional methods to increase its use by vulnerable 
populations. As part of this process, we are working with the London boroughs to understand how 
they share the alerts with their communities and explore how we can support them further to share 
the messaging.  

We are working with partners to improve our coordination with the NHS in order to enable the 
dissemination of the alerts to health authorities and London GPs. This process will require support 
from PHE and the NHS to ultimately enable the alerts to reach more vulnerable Londoners. This 

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 review is already underway with both boroughs and health partners, and we intend to share the 
findings and implement the suggested improvements this autumn.  

Air Quality Monitoring 

London has one of the most comprehensive air quality monitoring networks of any global city and 
air quality is constantly monitored at over 130 locations. These sites are operated and funded by 
the London boroughs, Transport for London (TfL) and Heathrow Airport. A number of these 
monitoring sites are included in the national Automatic Urban and Rural Network (AURN), which is 
the main network used for compliance reporting against the Ambient Air Quality Directives. 

To expand London’s monitoring capacity, in 2019 I piloted the Breathe London low cost sensor 
network, an air quality monitoring system that is being used to analyse pollution at known air 
quality hotspots across the city. As part of the pilot, over 100 sensors were fitted to lampposts and 
buildings, Google Street View cars took air quality measurements across the city and personal 
wearable monitors measured the exposure of children as they travelled to school.   

Following its successful pilot, I have since provided an additional £779,000 to fund 135 new 
Breathe London air quality sensors across London. These sensors are being delivered by Imperial 
College London. This new phase is prioritising hospitals, schools and community groups, as well as 
providing at least one sensor per borough. Sensors have already been installed at hospitals and 
reference sites with the remaining sensors to be installed by the end of July. Air quality data is now 
available through the Breathe London website (https://www.breathelondon.org/) which launched 
in March 2021, making it easier for all Londoners to access reliable, localised, real-time air quality 
data.  

I have also secured funding from Bloomberg Philanthropies who are contributing an additional 
£720,000 towards the Breathe London network to fund 60 more sensors over three years, in part 
to support a sponsorship programme that will enable organisations and individuals to apply for a 
free sensor. In response to demand, businesses and other groups will also be able to buy into the 
network, at a reduced rate, thereby choosing their own sensor location. Throughout June we will 
be hosting workshops with various stakeholder groups, including schools, businesses, and health 
organisations to raise awareness of the network and its benefits.  

The Greater London Authority (GLA) also hosts the public London Air Quality Map on the London 
Datastore. This tool shows the locations of air quality monitoring stations across London and links 
to the real-time air quality data. We work closely with the London boroughs as well as academic 
partners to promote this information and use the resulting data to inform both Londonwide and 
local policies.  

Information Campaigns 

I have arranged and funded regular marketing campaigns to raise awareness of the dangers of air 
pollution and ways individuals can reduce their contribution to it. In October 2017, I launched a 
hard-hitting advertising campaign to drive home the point that “if you could see London’s air, 
you’d want it clean too.” The campaign ran on social media and on posters across the TfL network. 
An example from the campaign is appended to this response.  

Other campaigns include #LetLondonBreathe, which helped raise awareness of a number of policy 
initiatives to improve air quality that I delivered in 2019, including the introduction of the central 
London ULEZ and London’s Car Free Day celebrations.  

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 The introduction of the central ULEZ in April 2019, was supported by an awareness campaign 
delivered in coordination with TfL to raise awareness of air pollution in London and highlight why 
the scheme was necessary to address it. This included social media content, posters, print, radio, 
online adverts and email newsletters as well as 600,000 letters sent through the DVLA to drivers 
with non-compliant vehicles. Similar activity began again in October 2020 and will run through to 
November 2021 to support preparations for the expansion of the ULEZ in October of this year. 
This will be further supported by a new Mayor of London air quality marketing campaign. 

Most recently, in February 2021 I joined 31 of the London boroughs in launching the Londonwide 
anti-idling marketing campaign “Engines Off. Every Stop.” This is part of the Idling Action London 
project funded through my Air Quality Fund. The aim of the campaign is to reduce unnecessary 
engine idling by raising awareness of how harmful toxic pollution can be to human health. An 
example from the campaign is appended to this response. 

I will continue to use the resources and platforms available to me to ensure more Londoners are 
aware of the health effects of air pollution and ways they can reduce their exposure and 
contribution to it.  

Case Making 

The GLA also regularly commissions research to inform policy decisions and design effective 
communication and behaviour change interventions. For example, the GLA has published research 
exploring the inequalities in air pollution exposure across different groups in London, particularly 
across different income levels and ethnic groups. This research will be updated later this year as 
new air quality modelling data becomes available and I will ensure it is reflected in my ongoing air 
quality programme.     

In 2021, we have commissioned a number of studies to provide additional evidence on the links 
between air pollution and health (respectively COVID-19 and other communicable diseases, and 
asthma). Additionally, we have commissioned work investigating how different transport choices 
can reduce an individual’s exposure to air pollution. This will be used to develop an online tool to 
inform and encourage individual behaviour change. The results of these studies will be published 
later this year and we will work with stakeholders from the health and care communities to ensure 
widespread dissemination of the findings.     

Borough Support 

As discussed during the inquest, in 2012 the GLA produced borough-specific air quality public 
health guidance to inform each borough’s Joint Strategic Needs Assessments (JSNAs) on air 
quality and Health and Wellbeing Strategy. The inquest highlighted the value of these documents 
and officers from my Air Quality and Health teams have since begun the process of preparing 
updated JSNA guidance documents, in collaboration with PHE. These documents will be shared 
with borough public health officers this autumn. To my knowledge, no other similar resources have 
been developed for use outside of London.  

The updated documents have been tailored to reflect the latest scientific evidence on both the 
impacts of, and solutions to, air pollution, in order to help facilitate and enhance collaboration 
between borough public health and air quality teams and inform policy. They will also bring 
together the latest health and air quality data and analysis for each of London’s boroughs.   

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 Collaboration 

I know that encouraging behaviour change is difficult and requires the continuous and widespread 
provision of detailed, accessible and actionable information, as well as consideration of the barriers 
and enablers of behavioural change, which are often unequally distributed. The scale of the 
challenge requires collaboration across national, regional and local government, as well as with 
non-governmental groups such as academia, NGOs and international bodies.  

I have hosted several national and international air quality summits, bringing together central 
Government, Metro Mayors and city leaders from across the UK as well as academics and medical 
professionals from across the globe to raise awareness of the problem of air pollution. Furthermore, 
I work closely with environmental and health NGOs to inform and amplify my policies and 
awareness campaigns. Through London’s leadership of the C40 Air Quality Network, the GLA 
shares lessons from London’s successful policies and learns from other interventions implemented 
by cities across the world. I will continue to work closely with these organisations to inform and 
broaden the reach of my work wherever possible.  

I am fully committed to working closely with Defra, the Department for Transport and the 
Department for Health and Social Care as well as the London boroughs to share examples of what 
has worked in London, and to improve scientific understanding, including of non-transport sources 
of pollution. I am also committed to working in partnership to promote existing and upcoming 
campaigns and sources of information to further raise public awareness. As part of this, I am 
exploring opportunities to bring together ministers and health professionals to agree on how best 
to take this collaboration forward in London.  

However, this cannot be achieved without national leadership. As a priority, I believe that 
Government should launch a national awareness campaign to amplify this crucial message on a 
scale much larger than can be delivered by regional and local government. I would also welcome 
further action from central Government, such as the creation of a national alerts system and the 
provision of additional funding for cities to develop and promote our own monitoring and 
awareness raising tools.  

First area of concern – World Health Organization (WHO) limits 

Your first area of concern sets out that the national limits for Particulate Matter (PM2.5) 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 area of concern is addressed to the central Government departments. 

I fully agree with your area of concern on this issue. In 2018, I set a target in my statutory London 
Environment Strategy for London to meet current WHO guidelines for PM2.5 no later than 2030. I 
have also signed London up to the WHO/UNEP Breathe Life Campaign, a network of 73 cities, 
regions and countries that have joined to demonstrate their commitment to bring air quality to safe 
levels by 2030 and collaborate on the clean air solutions that will help achieve this.  

Road transport is the largest individual source of local PM2.5 in London, accounting for 30 per cent 
of local emissions. Since 2016, I have taken a number of actions to tackle these emissions, through 
policies such as the early introduction and upcoming expansion of the ULEZ, introducing tougher 
standards for the Londonwide LEZ, upgrading the bus fleet to meet Euro VI standards and moving 
to zero emission buses, only licensing zero emission capable taxis since 2018 and encouraging 
mode shift to more sustainable forms of transport through record investment in walking and 

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 cycling. These measures have helped contribute to a 15 per cent reduction in PM2.5 concentrations 
since 2016.  

The GLA has set out in detail the key sources of PM2.5 for London and the additional measures 
needed to meet the WHO guidelines in a report published in October 2019. Despite having some of 
the highest concentrations of PM2.5 in the UK the report shows that, with the delegation of 
appropriate funding and powers, such as over construction machinery, commercial cooking and 
woodburning, it would be possible for London to meet this target. Additionally, around half of all 
PM2.5 measured in London comes from sources outside of the city, such as from industry and 
agriculture. This means a national approach to tackling air pollution is needed. 

If London can meet the target, with the multiple challenges it faces, so also can the rest of England 
and Wales. The GLA has submitted responses to Government consultations on the draft 
Environment Bill and on setting new targets for PM2.5. In these responses we highlighted the 
importance and achievability of setting legally binding PM2.5 targets based on the WHO guidelines. 
The Environment Bill provides an ideal opportunity to do so. I previously called on Government to 
introduce a new Clean Air Act. In its absence I would encourage the Government to, at the very 
least, take this opportunity to amend the Bill to enshrine the WHO targets in law. I remain 
committed to working with ministers to support their efforts and demonstrate how action in 
London can help inform national policy and ensure the rest of the country also meets these targets 
as rapidly as possible, delivering significant improvements to population health. 

Third area of concern – Communication of the adverse effects of air pollution on health 

Your third area of concern notes that 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 indicated that this needs to be addressed at three levels: (i) undergraduate 
education, (ii) postgraduate education and (iii) professional guidance. This area of concern is 
addressed to various professional organisations as listed in the PFD report.  

The London Health and Care Vision sets out the ambition shared by me, London Councils, the NHS 
and PHE to make London the world’s healthiest global city and the best global city in which to 
receive health and care services. Together we have identified 10 priority areas for pan-London 
collaboration, including improving air quality. Building on this, and in light of your PFD report, we 
have committed to work even more closely together to increase awareness of air pollution, its 
health impacts and mitigation measures, and to maximise health and care system support for vital 
structural changes such as the expansion of ULEZ and enabling more walking and cycling. This will 
also necessitate improved information sharing and communication across London’s health and care 
networks.  

We are working to develop the right structures to support this in London and exploring a range of 
approaches to drive engagement with frontline clinicians and carers, who are often best placed to 
provide this crucial information. However, this also requires Government leadership and national 
support from the relevant professional organisations to ensure this issue is prioritised and 
appropriately resourced.   

Conclusion 

The inquest into Ella’s death has underlined yet again the importance of urgent, ambitious and 
coordinated action to tackle air pollution. Every death and illness caused or worsened by living, 
studying or working in areas of poor air quality is an avoidable tragedy. I am fully committed to 

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 acting on your concerns and I look forward to working with Government, the London boroughs, 
clinicians and other health professionals and Londoners to do so.    

My ultimate ambition is for London to become a zero-pollution city, and I hope Ella’s legacy will be 
to inspire the change needed by all levels of government and the wider stakeholder community for 
this to happen.  

I trust this response is helpful. Please do not hesitate to contact me if I can be of any further 
assistance.   

Yours sincerely, 

Sadiq Khan 
Mayor of London                   

Appx. 

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 APPENDIX A – Examples of pan-London air quality awareness campaigns 

2017 air quality campaign poster  

2021 anti-idling campaign poster  

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2nd Floor 
2 Redmond Place 
London 
E20 1JQ 
United Kingdom 

10 May 2021 

Dr Philip Barlow 
Assistant Coroner 
London Inner South Coroner’s Court 
1 Tennis Street 
SE1 1YD 

Dear Dr Barlow, 

I write in response to your correspondence, dated 20 April 2021, regarding the tragic 
death of Ella Adoo Kissi-Debrah. I would like to express my sincere condolences to 
Ella’s family. 

We have considered the concerns raised in your report that are relevant to NICE’s 
work. Namely, that the adverse effects of air pollution on health are not being 
sufficiently communicated to patients and their carers by medical and nursing 
professionals and that this should be addressed by guidance aimed at professionals. 

Following the inquest into Ella’s death, NICE carried out an exceptional surveillance 
review of its guideline on asthma to assess whether the link between air pollution 
and asthma was appropriately covered. As a result of this process, the decision was 
made to amend the NICE guideline on asthma: diagnosis, monitoring and chronic 
asthma management NICE guideline (NG80) to acknowledge the link between air 
pollution and asthma. 

Amendments to the guideline were made in March 2021. Within recommendations 
1.10.1 and 1.10.5, we clarified that approaches to minimising indoor air pollution and 
reducing exposure to outdoor air pollution should be included in a personalised 
action plan because pollution can trigger and exacerbate asthma. We also added 
links to the NICE guidelines on air pollution: outdoor air quality and health and indoor 
air quality at home in recommendation 1.10.1. 

Separate to the above actions, the British Thoracic Society, Scottish Intercollegiate 
Guidelines Network and NICE are currently working together to produce UK-wide 
guidance on asthma diagnosis and monitoring and chronic asthma management that 
will update and replace the existing NICE guideline (NG80) once published. The 
expected publication date of this new joint guideline is yet to be scheduled. 

I hope the above information is useful. Thank you for requesting our contribution.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Professor 
Chief Executive 

                                                                                                                                 Page | 2

From the Chief Executive and Registrar 

Paul Brownlow 
Assistant Coroner of Inner London South Area 

8 June 2021 

Dear Mr Brownlow 

Prevention of Future Deaths Report for Ella Adoo Kissi-Debrah 

Thank you for sharing your Prevention of Future Deaths Report, and for giving us an 
opportunity to respond to the important concerns that you have raised. 

Before I address the concerns, I would like to extend my deepest sympathy to Ella’s 
family and friends. 

In your Report you have asked us to comment on the following areas: 

“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 evidence at the inquest was that this needs to be 
addressed at three levels: 

a. 

b. 

Undergraduate.  I am informed that undergraduate teaching is the 
responsibility of the GMC, Health Education England and the NMC. 

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.” 

As part of our response, I have set out in more detail our vision of building safe, 
effective and kind nursing care, and how we seek to achieve this.  I have addressed the 
specific areas of concern you have raised in relation to undergraduate and postgraduate 
education, and provided some additional information regarding our Code, professional 
standards of practice and behaviour for nurses, midwives and nursing associates that I 
hope you find helpful.  I have also identified three areas where we will reflect on the 
learning you have identified in your PFD Report, as follows: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   We will consider the concerns that you have raised in our evaluation of our new 
Future Nurse pre-registration standards, focussing on whether those standards 
are continuing to meet the requirements of what is necessary for safe and 
effective practice.  Moreover, whether the proper implementation of the 
standards by education institutions will play a part to reduce the risk of cases 
such as Ella’s arising again in the future. 

  We will consider the concerns that you have raised as part of our current 

consultation on post-registration standards, to ensure that the parts of our new 
Post Registration Standards for specialist community public health nursing and 
specialist practice qualifications for community nursing which relate to the 
prevention and management of ill health will reduce the risk of information not 
being communicated clearly. 

  We will identify if there is further activity that we can do to make sure that the 

professionals on our register understand their obligations to communicate clearly 
to their patients and their families about evidence related to the management and 
prevention of ill-health, and help prevent tragic cases such as Ella’s from 
occurring again. 

Our role 

Our vision is safe, effective and kind nursing and midwifery that improves everyone’s 
health and wellbeing.  As the professional regulator of almost 732,000 nursing and 
midwifery professionals, we have an important role to play in making this a reality. 

Our core role is to regulate.  First, we promote high education and professional 
standards for nurses and midwives across the UK, and nursing associates in England.  
Second, we maintain the register of professionals eligible to practise.  Third, we 
investigate concerns about nurses, midwives and nursing associates.  We believe in 
giving professionals the chance to address concerns, but we will always take action 
when needed. 

Undergraduate education for nursing professionals 

Nurses, midwives and nursing associates (in England) who wish to practise in the UK 
must be registered with us.  Professionals who are seeking to be registered with us 
must meet the standards of proficiency necessary for safe and effective practice, and 
additional requirements for registration, for example, our health and character 
requirements1. 

1 Article 5(2) of the Nursing and Midwifery Order 2001 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                            
 Nursing and midwifery professionals can demonstrate that they have met these 
standards of proficiency by completing approved qualifications, 2 which includes 
undergraduate education courses that have been approved by us in the UK3.  We also 
set programme standards and wider education standards, which enable our approved 
education institutions to deliver programmes related to our standards of proficiency4.  
The approved education institutions will design their curriculums to be able to meet our 
standards.  We set the standards and monitor the education institutions and 
programmes as part of our Quality Assurance activities5. 

In 2016, we embarked on a significant programme of change in relation to all of our 
education and training standards, which has included revising our standards of 
proficiency for nurses and midwives.  We introduced new standards of proficiency for 
registered nurses in 2018, (described as the Future Nurse standards6), and midwives in 
2019, (described as the Future Midwife standards7). 

The Future Nurse standards were approved by our Council, following extensive 
consultation and engagement over a two year period.  All undergraduate programmes in 
the UK have been approved against the new Future Nurse standards.  We expect the 
first nurses to graduate under these new standards in 2022. 

The Future Nurse standards of proficiency are arranged across a series of platforms, 
which detail the outcomes that we expect nurses who are seeking to register with us to 
have met.  We get this assurance from our approved education institutions. 

Platform 2 of the Future Nurse standards is described as “Promoting health and 
preventing ill health”.  The proficiencies that are detailed in this platform will equip the 
newly registered nurse with the underpinning knowledge and skills required for their role 
in health promotion, and protection and prevention of ill health.  At the point of 
registration, the nurse is expected to be able to understand the aims and principles of 
health promotion, improvement and prevention of ill-health, and be able to communicate 
appropriately in respect of these concerns.  I have set out below the relevant standards: 

“At the point of registration, the registered nurse will be able to: 

2.1.  understand and apply the aims and principles of health promotion, 
protection and improvement, and the prevention of ill health, when 
engaging with people. 

2.2.  demonstrate knowledge of epidemiology, demography, genomics and the 

wider determinants of health, illness and wellbeing, and apply this to an 
understanding of global patterns of health and wellbeing outcomes. 

2 Article 15 of the Nursing and Midwifery Order 2001 
3 Article 13 of the Nursing and Midwifery Order 2001 
4 Article 15(1) of the Nursing and Midwifery Order 2001 
5 Article 15(5) of the Nursing and Midwifery Order 2001 
6 ‘Future Nurse: standards of proficiency’, published May 2018 
https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/  
7 ‘Future Midwife: standards of proficiency’, published November 2019 
https://www.nmc.org.uk/standards/standards-for-midwives/standards-of-proficiency-for-midwives/ 

 
 
 
 
 
 
 
 
                                            
 2.9.  use appropriate communication skills and strength based approaches to 
support and enable people to make informed choices about their care to 
manage health challenges in order to have satisfying and fulfilling lives 
within the limitations caused by reduced capability, ill health and disability. 

2.10.  provide information in accessible ways to help people understand and 
make decisions about their health, life choices, illness and care”. 

While the standards do not expressly refer to environmental factors affecting health, we 
believe that these would be covered by the reference to “wider determinants of health” 
expressed in the standards. 

In addition to the Platform itself, we have also developed a detailed list of 
communication skills that we expect our nursing professionals to demonstrate at point of 
registration.  The communication skills draw together the communication techniques 
and skills required to communicate effectively, taking into account best practice and 
evidence the management and prevention of ill-health.  Here is an excerpt from 
Paragraph 2 of the communication skills annexe to the standards: 

“At the point of registration, the registered nurse will be able to safely 
demonstrate the following skills: 

2. 

Evidence-based, best practice approaches to communication for 
supporting people of all ages, their families and carers in preventing  
ill-health and in managing their care. 

2.1.  Share information and check understanding about the causes, 

implications and treatment of a range of common health conditions, 
including anxiety, depression, memory loss, diabetes, dementia, 
respiratory disease, cardiac disease, neurological disease, cancer,  
skin problems, immune deficiencies, psychosis, stroke and arthritis.” 

We therefore expect nurses who have completed programmes approved under our 
Future Nurse standards to be suitably equipped to communicate clearly the adverse 
effects about air pollution on health to patients, their families and carers. 

I have included the entirety of Platform 2 and Annexe A of the Future Nurse standards, 
which details the communication skills expected at point of registration, as an appendix 
to this letter. 

We will be carrying out an independent evaluation exercise of the Future Nurse 
standards.  As part of this exercise, we will reflect on the concerns raised by your report 
to help us understand whether the standards of proficiency are being used to their full 
potential.  We will use this exercise to consider whether the Future Nurse standards are 
continuing to meet the requirements of what is necessary for safe and effective practice.  
Moreover, whether the proper implementation of the standards by education institutions 
will reduce the risk of cases such as Ella’s arising again in the future. 

 
 
 
 
 
 
 
 
 
 
 
 
 Postgraduate education for nursing professionals 

Nurses and midwives who are initially registered with us may pursue additional 
qualifications that can also be registered with us.  We describe these as  
post-registration qualifications.  We do not set the requirements for all postgraduate 
education of nursing professionals. 

At present, we regulate two different types of post-registration qualifications.  If 
someone successfully undertakes a Specialist Community Public Health Nursing 
(SCPHN) course, they can join the SCPHN part of the register, in addition to the part of 
the register which indicates their initial registration as a nurse and/or a midwife.  The 
SCPHN part of the register also denotes the field of SCPHN practice.  Professionals 
can enter this register as a health visitor, school nurse, occupational health nurse, 
family health nurse or public health nurse.  This qualification also enables them to use 
the protected title ‘Specialist Community Public Health Nurse’, because it is protected in 
law by virtue of being a separate part of the NMC register. 

Nurses can also gain an NMC approved specialist practice qualification (SPQ).  This 
qualification is noted, or ‘annotated’, next to their name as it already appears on the 
register.  This demonstrates that they have successfully undertaken a course in a 
particular specialty that the NMC has approved, which the public can then check, but it 
does not confer exclusive use of any protected title associated with the qualification. 

As we have stated above, we are consulting8 on draft standards of proficiencies for 
SCPHN and SPQ, and accompanying programme standards.  The draft standards of 
proficiency have been designed taking into account the important lessons from the 
pandemic, and the role that public health and community nursing plays in the prevention 
and management of ill-health. 

As part of our consideration of the consultation responses, we will be reflecting on the 
concerns raised by your Report into Ella’s death to see if the proficiencies can be 
strengthened, so as to address those concerns. 

Our Code 

I note that you have not specifically asked about our Code, and have focussed on our 
education standards.  However, I think it is helpful to understand our expectations 
regarding the standards and behaviours for professional practice, and what we would 
hope nurses involved in the care of someone in a similar situation to Ella should 
consider. 

Once admitted to our register, our professionals are required to meet the requirements 
of our Code9.  The Code details professional practice and behaviours that all of our 
professionals must meet and reflect upon, as part of their revalidation and renewal of 
their registration every three years.10 

8 https://www.nmc.org.uk/about-us/consultations/current-consultations/future-community-nurse/  
9 https://www.nmc.org.uk/standards/code/read-the-code-online/  
10 Article 10 of the Nursing and Midwifery Order 2001 

 
 
 
 
 
 
 
 
 
                                            
 The Code requires nurses and midwifery professionals to communicate clearly and 
practise safely.  I highlight the following sections of the Code: 

“3.  Make sure that people’s physical, social and psychological needs are 

assessed and responded to 

To achieve this, you must: 

3.1.  pay special attention to promoting wellbeing, preventing ill health and 

meeting the changing health and care needs of people during all life 
stages. 

3.3.  act in partnership with those receiving care, helping them to access 

relevant health and social care, information and support when they need 
it. 

6. 

Always practise in line with the best available evidence 

To achieve this, you must: 

6.1.  make sure that any information or advice given is evidence-based, 

including information relating to using any health and care products or 
services. 

6.2.  maintain the knowledge and skills you need for safe and effective practice. 

7. 

Communicate clearly 

To achieve this, you must: 

7.1.  use terms that people in your care, colleagues and the public can 

understand. 

7.4. 

check people’s understanding from time to time, to keep misunderstanding 
or mistakes to a minimum”. 

With the above in mind, we would expect the professionals involved in situations similar 
to Ella’s to be able to communicate clearly with the family, providing information that is 
evidence-based, and using this to manage their condition. 

We will identify if there is further activity that we can do to make sure that the 
professionals on our register understand their obligations to communicate clearly to 
their patients about evidence related to the management and prevention of ill-health, 
and help prevent tragic cases such as Ella’s from occurring again. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Further information 

I have shared our response to the Prevention of Future Deaths Reports with the GMC 
and Professor 
hosted by Dr 
responses with Professor 
, Chief Nursing Officer for England, so 
that the Department and NHS England/Improvement can identify any common themes 
or joint work that the agencies can take forward together. 

 on 1 June 2021.  At that meeting, we agreed to share our 

, Chief Medical Officer as part of a multi-agency meeting 

 and 

I would also like to share that, as part of our Five Year Strategy, we have identified the 
impact of climate change on respiratory diseases, and we will continue to monitor 
environmental impact on our work as a regulator. 

I note that you have not mentioned concerns regarding individual professionals in your 
Report.  If you believe there are specific concerns we should be considering, please let 
us know. 

I hope this information provides you with information about our standards in nursing and 
midwifery education, and the steps we are taking to minimise the risk of future deaths 
occurring as a result of any potential gaps in the education of our professional 
standards for registered nurses, midwives and nursing associates. 

Once more, I would like to offer my deepest sympathy to Ella’s family and friends. 

Yours sincerely 

Chief Executive and Registrar 

c.c.  Professor 
Care 

, Chief Medical Officer, Department of Health and Social 

, Chief Nursing Officer, England 

, Chief Executive and Registrar, General Medical Council

RC Royal College of
GP General Practitioners

Dr
Joint Honorary Secretary

Mr Philip Barlow
HM Assistant Coroner for the coroner area of Inner South London
Sent by email to:

28 May 2021
Dear Mr Barlow,

Regulation 28 Report to Prevent Future Deaths - touching on the death of Ella Adoo Kissi-
Debrah

Thank you for your report of 20 April 2021. | am responding on behalf of the Royal College of
General Practitioners as Joint Honorary Secretary to Council. Firstly, can | convey our
condolences to the family and friends of Ella. | was saddened to read of Ella's passing.

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the
United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of
general medical practice and to act as the ‘voice’ of GPs on issues concerned with education;
training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000
members who are committed to improving patient care, developing their own skills and
promoting general practice as a discipline.

RCGP has been working to raise the profile of impact of pollution at public health and policy
levels and also with members, practices and patients. In preparing this response, | am indebted to
colleagues in helping to draft a reply to your Regulation 28 letter. | would particularly like to

| Cl their assistance.
As RCGP, we support the "Greener Practice Networks” approach, which has a significant

emphasis on air pollution. See here for details. The RCGP has for several years encouraged
engagement of practices In the Green Impact Audit for Health (see here) which includes
encouragement for practices to address the use of cars for transport by staff and patients ; this is
part of the work supported by the college's Climate Change Emergency Advisory Group which is

jointly chaired by Or es? a former RCGP President, Dr PY We also work

with the Primary Care Respiratory Society, which is clear regarding the impact of pollution on
respiratory function. See here for details.

We are also aware that Health Education England are considering an on-line planetary education
programme. RCGP is already in the process of producing a planetary health element of
curriculum that all new GP will be assessed against. In the near term we are also planning a high
profile webinar that GPs would be able to access and whilst it would have a broader approach to
planetary change, it would incorporate elements regarding pollution.

RCGP is supportive of the use of non-carbon transport. In line with a change to our commercial
policies, we emphasise electric modes of transport as well as where appropriate, supporting the
use of bicycles, such as that arranged by our Wessex Faculty (see here for details).

Finally, RCGP as an organisation has undertaken its own environmental audits and we continue
to work to reduce our own carbon footprint. We were also the first Royal College to make a
strategic decision to disinvest in organisations that are involved with fossil fuels.

Overall we consider that there is much work to be done to support efforts to reduce the impacts
of climate change and within this the effects of air pollution. Our view is that this would
significantly improve the health of both current and future patients as well as be better for our
planet.

| trust that this reply is helpful and if you have any questions, please do not hesitate to contact
me.

Yours sincerely,

Dr|
Joint Honorary Secretary of Council
Royal College of General Practitioners

5-11 Theobalds Road  
London  
WC1X 8SH  
- 

www.rcpch.ac.uk 

Friday, 11 June 2021 

Sent by email to: 

Dear Assistant Coroner P Barlow  

Re: Ella Adoo Kissi- Debrah  
Regulation 28 – Action to Prevent Future Deaths 

We  have  read  carefully  your  report  regarding  the  tragic  and  untimely  death  of  Ella  Adoo  Kissi- 
Debrah and have discussed this with senior colleagues within the RCPCH. 

The RCPCH supports, educates and develops paediatricians, and the wider child health workforce 
and  services,  to  deliver  high  quality  safe  care  for  infants,  children  and  young  people.  You  have 
asked  us  to  respond  to  your  concern  that  the  adverse  effects  of  air  pollution  on  health  are  not 
being  sufficiently  communicated  to  patients  and  their  carers  by  medical  professionals.  Through 
our  political  advocacy  work  on  child  health,  we  believe  we  can  also  contribute  to  some  of  your 
concerns around actions that need to be considered by local and national government.   

In line with the GMC standards,1 all medical curricula have moved away from being prescriptive in 
relation  to  disease  and  conditions,  to  focus  on  capabilities  and  learning  outcomes.  The  RCPCH 
curriculum  includes  a  domain  on  health  promotion,  requiring  all  paediatricians  to  demonstrate 
capabilities around understanding the environment, economic and cultural contexts of health and 
healthcare illness on illness prevention.2 Paediatricians who subspecialise in paediatric respiratory 
medicine will cover these capabilities in greater depth.  

At a national level, the College is working with the children’s team at NHS England/Improvement 
and Health Education England to develop asthma competencies for child health professionals and 
carers.  The  College’s  own  educational  course  on  improving  asthma  care  considers  the  wider 
determinants of outcomes in asthma for children.   

Our  joint  report  with  the  Royal  College  of  Physicians  in  2016,  Every  breath  we  take:  the  lifelong 
impact of air pollution brought forward the commitment from health professionals to explore the 
available evidence and develop recommendations on the role air pollution plays to adverse health 
outcomes, clearly exposing instances of avoidable illness’, disability, and death.3  

1 https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/excellence-by-design  
2 https://www.rcpch.ac.uk/education-careers/training/progress/curriculum#domain-5---health-promotion-and-illness-
prevention-gpc-4  
3 https://www.rcplondon.ac.uk/projects/outputs/every-breath-we-take-lifelong-impact-air-pollution  

Charityin England and Wales: 1057744  Registered charity in Scotland SCO38299 
- 
PATRON HRH The Princess Royal 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
	
	
 
 The  College’s  State  of  Child  Health  report  reveals  the  UK  as  having  one  of  the  highest  rates  of 
asthma deaths among 10 to 24-year-olds in Europe.4 5 Emergency admissions, and deaths, relating 
to asthma are largely preventable with improved management and early intervention, and sadly 
these poor outcomes are strongly associated with deprivation. In January 2020, we published two 
major  pieces  of  research  and  policy  advocacy  to  highlight  the  threat  of  air  quality  to  health 
outcomes for children, which I will go on to describe.  

Our  position  statement  on  outdoor  air  quality  in  the  UK,  strongly  supports  national  policies, 
practices  and  legislations  that  aim  to  improve  outdoor  air  quality  and  advocates  for  sharing 
information and supporting the public to act.6 We recognise that everyone has a responsibility for 
reducing  air  pollution  and  have  urged  paediatricians  to  be  aware  of  our  position  on  outdoor  air 
quality, and use it to inform patients and their families of the health impacts and encourage and 
support  them  to  make  positive  changes  to  improve  air  quality  and  reduce  their  exposure  to  air 
pollution. We also ask that paediatricians act as role models for others and make personal changes 
to  reduce  air  pollution  where  possible,  and  that  they  encourage  change  within  their  workplace 
and  the  wider  NHS.  Finally,  we  ask  that  paediatricians  are  made  aware  of  local  and  national 
initiatives to improve air quality and signpost families to relevant resources.  

The College’s research study The inside story: Health effects of indoor air quality on children and 
young people was clear that the responsibility for clean air cannot solely rest with individuals and 
urged government and local authorities to develop a national strategy and set indoor air quality 
standards.7  It  specifically  asks  that  more  assistance  is  provided  for  people  in  rented  and  social 
housing  to  report  air  quality  problems,  recognising  that  social  deprivation  plays  a  major  role  in 
driving poor health outcomes.  

We  are  committed  to  leading  the  way  to  adopt  ways  of  working  and  policies  that  support 
improvements  in  outdoor  air  quality.  In  October  2020  we  joined  many  other  organisations  in 
declaring  a  climate  emergency,  highlighting  the  detrimental  impacts  of  air  pollution  on  younger 
people.8 Climate change has been identified as a priority in our new College strategy for 2021-24, 
and  we  are  in  the  process  of  establishing  a  comprehensive  programme  of  work  which  will  be 
driven by our members. Our ambitious aims include:  

•  effectively  using  our  collective  voice  and  expertise  as  paediatricians  to  influence  the 
national  and  international  climate  change  agenda,  focusing  in  particular  on  the  health 
impacts faced by children and young people now and in the future 

•  advancing  research  on  the  effects  of  climate  change  on  child  health  inequalities  and  on 

the impacts of the climate crisis on young people’s physical and mental health 

•  developing  and  promoting  training  for  our  members  on  key  aspects  of  sustainable 
healthcare and the climate crisis, including communication about this topic with patients 
and families 

4 https://stateofchildhealth.rcpch.ac.uk/evidence/long-term-conditions/asthma/#page-section-4  
5 https://www.rcpch.ac.uk/sites/default/files/2018-10/child_health_in_2030_in_england_-report_2018-10.pdf  
6 https://www.rcpch.ac.uk/resources/outdoor-air-quality-uk-position-statement#key-messages-for-health-professionals  
7 https://www.rcpch.ac.uk/resources/inside-story-health-effects-indoor-air-quality-children-young-people#what-did-
we-find  
8 https://www.rcpch.ac.uk/news-events/news/uk-paediatricians-declare-climate-emergency  

Charityin England and Wales: 1057744  Registered charity in Scotland SCO38299 
- 
PATRON HRH The Princess Royal 

 
 
 
 
 
 
 • 

supporting  our  members  to  advocate  for  improved  sustainability  locally  in  their  clinical 
work and workplaces as well as supporting the wider national ambition for the NHS to be 
net zero by 2040 

Please see our priorities for action for more information.9 

The RCPCH is a member of the UK Health Alliance on Climate Change10 and continues to work in 
partnership with others to advocate for responses to climate change that protects and promotes 
public  health. In  June  we  will  be  marking  Clean  Air  Day  with  our  members  and  showing  our 
support for this year’s theme ‘let’s protect our children’s health from air pollution’.  

We welcome the NHS Long Term Plan’s commitment to renew its NHS prevention programme and 
recognise the opportunities brought forward by the upcoming  Health and Social Care  Bill where 
integrated care systems (ICS) will provide the basis for health organisations and local authorities to 
improve  upstream  prevention  of  avoidable  illness.  It  is  critically  important  that  children  are 
represented  at  strategic  level  in  ICSs  so  they  reap  the  benefits  of  evidence-based  planning  with 
sufficient  resource  to  meet  their  needs.  We  will  be  supporting  this  year’s  #AskAboutAsthma 
campaign  as  the  NHS  in  London  ask  sufferers  to  ‘take  three  small  steps  to  improve  lives.’  This 
includes  a  reminder  to  have  an  annual  asthma  review,  ensure  inhaler  techniques  are  right  and 
make sure an asthma plan is in place and well understood. 

Thank you for raising this case with us and reminding us of the importance of this work.  

Yours sincerely 

Dr 
President, Royal College of Paediatrics and Child Health 

9 https://www.rcpch.ac.uk/resources/tackling-climate-change  
10 http://www.ukhealthalliance.org/  

Charityin England and Wales: 1057744  Registered charity in Scotland SCO38299 
- 
PATRON HRH The Princess Royal

From the Registrar 

Dr 

Royal College of Physicians 
11 St Andrews Place 
Regent’s Park 
London NW1 4LE 

www.rcplondon.ac.uk 

Mr Philip Barlow 
Assistant coroner 
HM Coroner for the Inner South District of Greater London 
1 Tennis Street 
London 
SE1 1YD 

04 June 2021 

Dear Mr Barlow 

Re: Regulation 28 report to prevent future deaths following the death of Ella Adoo-Kissi-Debrah 

Please find below the Royal College of Physicians’ (RCP) response to your Regulation 28 report of 20 
April 2021. As requested, we have responded to your concern that the adverse effects of air pollution 
on health are not being sufficiently communicated to patients and their carers by medical and nursing 
professionals. You will already be aware of the expert opinion we provided in a previous response to a 
Regulation  28  report  in  the  form  of  our  joint  report  with  RCPCH,  Every  breath  we  take:  the  lifelong 
impact of air pollution. 

We think the actions we lay out will help increase understanding of and facilitate conversations with 
patients on avoiding and mitigating the dangers of air pollution. But the risk of air pollution to public 
health will only be significantly reduced if government and other policy makers agree to widespread 
societal measures, particularly more regulation of pollution generating activity. Initiatives need to be 
focused on reducing the exposure of women, children, older people, and people in lower socioeconomic 
groups, in which ethnic minorities are overrepresented. 

Yours sincerely, 

Dr 
Registrar, Royal College of Physicians 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 RCP response to the Regulation 28 report to prevent future deaths following the death of 

Ella Adoo Kissi-Debrah 

1.  The RCP accepts the evidence, presented at the inquest by our special adviser on air quality Professor 

  among  others,  that  the  adverse  effects  of  air  pollution  on  health  are  not  being 

sufficiently communicated to patients and their carers by medical professionals. We thank the assistant 

coroner for the coroner area of Inner South London for bringing it to our attention. 

2.  Air pollution is of great concern to all physicians, not just respiratory specialists, which is why we helped 

established the UK Health Alliance on Climate Change. Its impacts can be profound, particularly for the 

developing  foetus,  children  and  young  people,  and  people  living  in  more  deprived  areas.  As  well  as 

adversely affecting lung development and growth, it can cause diseases and conditions of the lungs. It 

can also cause or exacerbate cancer, heart disease, cognitive problems and diabetes. 

3.  We  produced  this  response  with  the  Joint  Royal  Colleges  of  Physicians’  Training  Board  (JRCPTB),  the 

Faculty of Public Health, the British Thoracic Society, the Association of Cancer Physicians, Association of 

British Neurologists, the British Society for Clinical Neurophysiology, the Association of British Clinical 

Diabetologists and the Society for Endocrinology. 

The medical curriculum 

4.  The  postgraduate  internal  medicine  curriculum  is  followed  by  everyone  training  in  the  32  physician 

specialties. It requires trainees to: 

a.  Understand the factors which influence the incidence of and prevalence of common conditions. 

b.  Understand  the  factors which  influence  health  –  psychological,  biological,  social,  cultural  and 

economic especially work and poverty. 

c.  Understand the influence of lifestyle on health and the factors that influence an individual to 

change their lifestyle. 

d.  Understand the relationship between the health of an individual and that of a community. 

e.  Understand  the  role  of  other  agencies  and  factors  including  the  impact  of  globalisation  in 

f. 

g. 

protecting and promoting health. 

Identify opportunities to prevent ill health and disease in patients. 

Identify  opportunities  to  promote  changes  in  lifestyle  and  other  actions  which  will  positively 

improve health, e.g. to encourage smoking cessation and / or weight reduction. 

h.  Work collaboratively with others to encourage patients to safely reduce their weight if obese and 

increase their physical activity / exercise. 

1 

 
 
 
 5.  The  curriculum  does  not  specifically  mention  air  pollution,  but  it  does  reference  the  GMC’s  General 

Professional  Capabilities,  which  do  include  Health  Promotion  and  Illness  Prevention.  We  accept  that 

there needs to be better understanding by doctors of the impacts of air pollution on health so we will 

a.  review the delivery of the curriculum at local level 

b.  add some questions on air pollution to the exams we administer 

c.  work  with  the  relevant  specialist  societies  to  decide  how  to  increase  knowledge  among 

physicians of the impacts of air pollution on health. 

Communication with patients, families and carers 

6.  There is lots of information available about the impacts of air pollution and the medical community does 

produce its own reports and events. The RCP and RCPCH 2016 report Every Breath You Take and its 2018 

update, for example, were widely read and are still referenced and discussed. But we need to do more 

to communicate the large amount of scientific evidence available as it makes the case for why medical 

practitioners need to communicate with patients. 

7.  Doctors, and all healthcare professionals, need to understand that they have a responsibility to talk to 

patients about air pollution and how to avoid it. But knowing about the dangers of air pollution is very 

different from talking to patients about them, and we recognise that we have an important role to play 

in helping doctors do this. Many patients and their families will not be able to make the changes that will 

have the most benefit – that is, change where they live, work and play - so doctors and other clinicians 

may be uncertain of the benefits of such a conversation. It is understandable that they may shy away 

from these conversations, so we must give them the confidence to know there is something they can do 

to help. 

8.  We will therefore look to produce and actively promote resources that will help medical professionals to 

better understand the impacts of pollution and have effective conversations with patients. The resources 

may include written guides, podcast episodes, online learning and events. They may be produced by the 

RCP, specialist societies, or in collaboration through the Academy of Medical Royal Colleges and with 

other partners. We will urge all of our 32 specialties to help develop and subsequently promote such 

resources through their networks. The March 2021 updated NICE guideline on asthma, plus its guideline 

on air pollution: outdoor air quality and health and its guideline on indoor air quality at home, will be 

instructive. 

2 

 
 
 
 
 9.  While  we  will  work  with  our  members  to  develop  them,  we  think  the  resources  to  help  facilitate 

conversations should focus on outlining what most people might be able to do to reduce their or their 

family’s exposure to pollution. That is likely to include how someone can 

a.  reduce indoor air pollution, such as what cleaning products to use, not smoking in the home, not 

burning fuel in the home, ventilation and when not to open windows 

b.  mitigate the adverse biological effects of exposure to the air pollution that they may have no 

control over, such as by eating certain foods and improving nutrition 

c.  avoid  outdoor  air  pollution  when  possible,  including  the  promotion  of  apps  that  provide 

information about local pollution levels 

d.  understand which conditions exacerbate the impacts of air pollution, such as obesity, and how 

they can be addressed. 

10. At  the  same  time,  more  needs  to  be  done  to  help  doctors  and  others  know  when  to  have  these 

conversations. For example, electronic patient record systems in primary and secondary care could alert 

them when someone is living in an area of high pollution. An indicator could be added to the Quality and 

Outcomes Framework (QOF). 

11. Finally, we will consider how we might help medical professionals become local advocates for reducing 

air pollution. The NHS’ adoption in 2020 of a multiyear plan to become the world’s first carbon net zero 

national health system and its Greener NHS campaign offer opportunities to raise the medical voice on 

this issue. 

Regulation of pollution generating activity 

12. Most important is government action to reduce air pollution, particularly more regulation of pollution 

generating  activity.  There  needs  to  be  a  particular  focus  on  initiatives  that  reduce  the  exposure  of 

women, children, older people, and people in lower socioeconomic groups, in which ethnic minorities 

are overrepresented. 

13. We agree with the assistant coroner that the national limits for particulate matter are too high, that the 

WHO guidelines should be seen as minimum requirements, and that  legally binding targets based on 

them would reduce deaths in the UK. The environment bill currently making its way through Parliament 

is an opportunity to do just this. 

14. We need more clean air zones in the most polluted towns and cities. The use of Ultra Low Emission Zones, 

such  as  that  in London,  should  be  expanded.  Every  attempt  should  be  made  to  ensure  that  traffic  is 

directed away from areas of socioeconomic deprivation, as this exacerbates health inequalities. 

3 

 
 
 15. Greater thought needs to be given to housing regulations. Particularly in the construction of social, low-

income and affordable housing, regulations must reduce indoor pollutants. Careful consideration must 

be given to where new housing is built so that areas of high pollution are avoided. 

Public information 

16. In  many  other  countries,  such  as  the  US,  Australia  and  Japan,  it  is  common  to  have  daily  reports  of 

pollution on television and radio. These reports help people to manage their own exposure and risk. Daily 

pollution  reports  should  be  added  to  weather  reports  on TV,  radio  and online  in the  UK.  At  times of 

particularly  high  pollution  levels,  the  government  should  issue  alerts.  The  government  should  also 

promote apps that people can use to monitor levels locally, much as the NHS COVID-19 app alerts people 

to the level of coronavirus risk in their postcode area. 

17. Local authorities have an important role to play, not least in communicating local pollution scores and 

explaining what they mean to the community. This may include recommending that certain groups do 

not go out at times when pollution is particularly high, avoid particular roads or areas, and don’t open 

windows at certain times. Local authorities also have a role  in making sure air pollution is a factor in 

housing allocation decisions. 

18. Schools could also be a good vehicle for communicating the dangers of air pollution and how to avoid or 

mitigate them. Physicians could have a role in working with them. 

19. Integrated care systems, which will soon be put on a legal footing through the forthcoming health and 

care bill, present us with an opportunity in this regard. As partnerships between local authorities, health 

and care services, and the voluntary and community sector, they will be ideal forums for discussing the 

local situation and deciding how best to bring all this together for the better health of their populations. 

4 

 
 
 
 
 Summary of actions 

The Royal College of Physicians will work with specialist societies, the Academy of Medical Royal Colleges 

and other royal college partners, the UK Health Alliance on Climate Change and others to 

• 

• 

continue to raise the profile of the impacts of air pollution on health 

review the delivery of the internal medicine curriculum in light of this report 

•  work with specialist societies to decide how to increase knowledge among physicians of the impacts 

of air pollution on health 

•  produce and actively promote resources that will help medical professionals 

o  better understand the impacts of pollution 

o  have  conversations  with  patients  and  their  families  about  avoiding  air  pollution  and 

mitigating its impacts 

•  work with government and the NHS to improve incentives to have these conversations and systems 

that indicate when they are necessary 

• 

consider how we might help medical professionals become local advocates for reducing air pollution 

•  urge national and local government to tighten regulation of pollution generating activity and improve 

public information. 

5

Dear Mr Barlow,

RE: Report to Prevent Future Deaths, published Tuesday 20 April 2020

Thursday 17 June 2021

We are writing in response to your Report to Prevent Future Deaths after the tragic death of Ella Adoo
Kissi-Debrah. Air quality was deemed a significant contributory factor to her asthma and a cause of
her death. Today also happens to be Clean Air Day, a day when many organisations and individuals
remind us of our need (indeed, our right ) to breathe clean air.

2

1

The UK Health Alliance on Climate Change (UKHACC) was founded in April 2016, bringing together
leading health bodies to advocate for responses to climate change that protect and promote health.
Several Alliance members were named in your report.

Your report is a vital reminder of the need for strong action to protect people’s health, improving the air
we all breathe. Though air pollution can affect us all, it does not do so equally. Evidence has found, for
example, that people from more deprived areas and from ethnic minority groups are more likely to
experience poor air quality. Air quality is highly likely to have played a role in exacerbating
inequalities in vulnerability to COVID - as people with health conditions due to air pollution are more at
risk of severe COVID complications.4

3

UKHACC fully supports the recommendations that health professionals offer advice to their patients
around air quality, and be appropriately trained to do so. With Global Action Plan, UKHACC delivered
a pilot project, jointly funded by Defra and the Clean Air Fund, to educate and enable paediatricians
and respiratory health professionals to provide better advice to their patients on air pollution. This
included developing materials and delivering training online across the UK. The lessons from this
pilot can help to inform future training for health professionals.

5

Our members’ responses highlight the diversity and strength of the actions our members are taking.
From reports describing the health impacts of air pollution, to reviewing the training that is delivered to
health professionals, to hosting online resources and guidance documents, our members are taking
action to support health professionals in appropriately incorporating advice on air quality into the care
they provide.

While there is advice that health professionals can give to patients, more research is required to
ascertain whether this advice will translate into reduced exposure to air pollution or improved
outcomes. Training and information for health professionals must be situated in the context of wider
systemic change that enables air quality to be routinely incorporated into care pathways. This might
involve, for example, clear integration of air quality data with A&E information systems so that

6

1 Barlow, P., 2021. Report to prevent future deaths
2 UN, 2019. Issue of human rights obligations relating to the enjoyment of a safe, clean, healthy and sustainable
environment
3 Fecht et al., 2015. Associations between air pollution and socioeconomic characteristics, ethnicity and age
profile of neighbourhoods in England and the Netherlands. Environ Pollut.198:201-10
4 Travaglio et al., 2021. Links between air pollution and COVID-19 in England. Environ Pollut. 268(Pt A):115859
5 Global Action Plan. Healthcare resources
6 Whitehouse & Grigg, 2021. Air pollution and children’s health: where next? BMJ Paediatrics Open

 clinicians are made aware of air quality as a potential factor in admissions from respiratory or
cardiovascular disease. Other technology such as air pollution notifications via apps may help patients
to self manage their conditions.

Fully protecting individuals may require clear pathways for referral to housing services, to support
individuals at high risk in moving home - though these services would clearly require significant
resources to achieve this.

However, we must recognise the limitations of healthcare in addressing this problem and we need
urgent action to prevent air pollution from arising in the first place. The recommendation for WHO
legal limits is something the UK Health Alliance on Climate Change fully supports, and has been
calling for since at least 2018. While some of our other recommendations have been taken up, such
as a ban on the sale of petrol and diesel vehicles, a binding limit for air quality has yet to be
incorporated in law. The Environment Bill is a unique opportunity for policy-makers to ensure that this
limit becomes a legal requirement which can be used to enforce action. Along with this legal limit,
continued investment in active travel and scaling up Clean Air Zones will be vital measures in
delivering cleaner air.

7

Let us make 2021 a turning point where we secure the right to clean air for all.

Yours sincerely,

Dr 
Chair
UK Health Alliance on Climate Change

Dr 
Interim Director
UK Health Alliance on Climate Change

7 UKHACC, 2018. Moving Beyond the Air Quality Crisis