Prevention of Future Deaths reports · 2022

Awaab Ishak

Regulation 28 report to prevent future deaths, reference 2022-0365, written 16 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Nov 2022
Reference2022-0365
DeceasedAwaab Ishak
CoronerJoanne Kearsley
Coroner areaManchester North
CategoryChild Death (from 2015) · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published4

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Mr  Michael  Gove,  Minister  for  Housing,  Department  for  Levelling  Up,  Housing  and 

Communities 

2.  Mr Steve Barclay,  Secretary of State for Health 

CORONER 

I am  Joanne Kearsley,  Senior Coroner for the Coroner area of Manchester North 

2 

CORONER'S LEGAL POWERS 

I  make  this  report  under  paragraph  7,  Schedule  5,  of the  Coroner's  and  Justice  Act  2009  and 
Regulations 28 and  29 of the Coroners (Investigations) Regulations 2013 

3 

. INVESTIGATION and INQUEST 

On the 27th  December 2020,  I commenced an investigation into the death of Awaab Ishak 

Awaab  died  on  the  21 st  December 2020  at the  Royal  Oldham  Hospital.  He was 2 years  old.  The 
investigation concluded on the 15th  November 2022.  The medical cause of death was confirmed as 
1a) Acute  Airway oedema  with  severe  granulomatous tracheobronchitis  due to  1b) Environmental 
mould exposure. 

I recorded  a narrative  conclusion:  Awaab  Ishak died  as  a  result of a  severe  respiratory  condition 
due to prolonged exposure to mould in his home environment. Action to treat and prevent the mould, 
was  not taken.  His respiratory condition  led  to  a respiratory arrest.  The medical advice given to  his 
parents  led  to  Awaab  receiving  sub-optimal  airway  ventilation  which  was  unable  to  prevent  his 
cardiac arrest. 

4 

CIRCUMSTANCES OF DEATH · 

Awaab lived with his parents at 
, Rochdale. This property is owned by 
Rochdale  Boroughwide housing association ("RBH").  In  2017 the  presence of mould  in  the flat was 
notified to RBH. The advice given to 
had  recently arrived  in  the  UK from  Sudan.  The fact this needed to  be with  specialist paint was not 
made clear to  him. 

 (Awaab's father) was to, "paint over it." 

In 2018 Awaab was born.  I am satisfied from the evidence that the mould remained a continuing and 
recurrent issue whilst the family were  in  the  property,  albeit no further complaint was made to  RBH 
until July 2020.  In 2019 the family made an  application to be re-housed. 

In  July 2020 the family showed  a Health visitor the  mould  and a letter was sent dated 9th  July 2020 
to  RBH  by  the  health  visitor  explaining  their  concerns  about  the  mould  and  potential  impact  on 
Awaabs health. Throughout his life Awaab had recurring cold symptoms such as runny nose, cough, 
and  respiratory tract infections.  His GP confirmed that he attended at their surgery more than  most 
children. 

In June 2020 the family instructed solicitors to make a disrepair claim due to the mould.  An inspection 
carried  out  by  RBH  on  the  14th  July  2020  confirmed  the  presence  of  mould  in  the · kitchen  and 
bathroom.  The policy at the time was not to  progress to repair and treatment until th~ agreement of 
the solicitors had  been obtained. 

 
 No action had  been taken to treat the mould by the time Awaab died. 

At the time of his death significant mould was  present in  all the rooms in the flat. 

During the course of the Inquest the court heard evidence from the Housing Ombudsman regarding 
their October 2021  report  SPOTLIGHT on  damp and  mould.  Many of the  themes they had  noted 
from  the increased number of complaints to them were found  in  Awaab's case,  namely: 

-

-

-

Professionals  placing  too  much  emphasis  on  the  ·cause  of the  mould  being  due  to  "family 
lifestyle." In fact as 
 indicated, homes need to be habitable for modern living.  There 
is  no  evidence  the  family  lived  an  "excessive"  lifestyle  and  the  daily  activities  of living  which 
contributed  to  the  damp  and  condensation  were  normal  activities  such  as  cooking,  washing, 
bathing and drying clothes. 
There  was  a  lack  of  proactive  action  to  consider  wider  potential  sources  of damp · such  as 
structural.  However I did not find that there were any structural issues such as leaks etc. 
There was a lack of proactive treatment of the mould and a lack of consideration of the ineffective 
ventilation within this ageing property.  In this case there was a fan in the bathroom which did not 
work effectively,  there was no mechanical ventilation in the kitchen at all.  There was no window 
in the bathroom and the window in  the kitchen opened onto the communal walkway. 

The court heard evidence that the impact on health from damp and  mould  is  a widespread  national 
issue.  Of particular ·importance  is  the  fact  this  is  not  simply  a  social  housing  issue.  The  same 
concerns  apply as  much  to  the  private  landlords,  where  evidence  suggests the  problem  is  worse. 
The October 2021  Spotlight report by the Housing Ombudsman makes this clear. 

  Consultant  Mycologist  sampled  the  mould  from  within  the  home  following 
Awaab's  death.  He gave evidence  to  the  court on  the  illnesses  and  harm,  including  death,  which 
can arise from the inhalation of fungi from mould.  It was apparent that updated information regarding 
the current health risks relating to damp and mould are not widely available or known to the housing 
sector. 

 compared the information sharing,  campaigns and  primary legislation which surround 
gas safety and legionnaires which have been hugely beneficial.  In comparison there is a lack of the 
·same information or legislation in  respect of damp and  mould. 

The court heard from the housing association regarding the challenges they face due to the reliance 
on  ageing  housing  stock,  the  lack  of new  builds  to  create  increased  property  numbers,  lengthier 
waiting lists for people who are requesting social housing and the impact of mandatory changes such 
as the need to be carbon neutral.  It was clear that RBH have learnt many lessons following Awaab's 
death. 

Following Awaab's death the local authority carried out a Housing  Health and  Safety Rating System 
("HHSRS") report. The HHSRS is used to  assess the suitability of properties under the  Housing Act 
2004.  This  is  the  local  authority  tool  used  with  a  view  to  engaging  landlords  and  enforcing  any 
remedial  action required.  This rating sheet is outdated for damp and mould. 

Post mortem examination of Awaab and  subsequent testing confirmed the presence of granulomas. 
The  Forensic pathologist was  able to  rule  out all qther causes of these and  directly concluded  that 
prolonged exposure to mould led to Awaab's respiratory arrest. 

5 

CORONE~SCONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern.  In my opinion 
there  is  a  risk  that future  deaths  will  occur  unless  action  is  taken. 
In  the  circumstances  it  is  my 
statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:-

1.  The 2006 document, "A Decent Home: Definition and Guidance for Implementation" does not 
give any consideration to the issue of damp and mould.  Nor does it provide any guidance as 
to the need for a property to be adequately ventilated. 

2.  The HHSRS data sheet relating to damp and mould,  is used to calculate risks of the incident 
and  the spread  of harm  is  not reflective  of the  current known  risks  of damp and  mould  and 
harm to health. 

 3.  There was  no  evidence that up to  date relevant  health  information pertaining  to  the risks  of 

damp and mould was easily accessible to the housing sector. 

4.  The  evidence  highlighted  a  "policy"  amongst the  housing  associations,  in  cases  where  a 
disrepair claim  has  been  brought of waiting  for agreement from  the  claimant (or their legal 
representative) before rectifying any recognised  disrepair. 

5.  The  private  landlord  sector  does  not  have  access  to  the  Housing  Ombudsman  for  their 
. 

com  laints to be investi 

· 

6 

ACTION  SHOULD BE TAKEN 

In  my  opinion  action  should  be  taken  to  prevent  future  deaths  and  I  believe  each  of you 
respectively have the power to take such action. 

7 

YOUR RESPONSE 

You  are under a duty to  respond  to this report within  56  days of the date of this report,  namely 13th 
January 2023.  I,  the Coroner,  may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the timetable 
for action.  Otherwise you  must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following  Interested Persons namely:-

Family of Awaab Ishak 
Rochdale Boroughwide Housing Association 
Rochdale Borough Council 
Northern Care Alliance 

I am  also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both  in  a complete or redacted or summary from.  He may 
send  a copy of this  report to any person who he  believes  may find  it useful or of interest.  You  may 
make  representations  to  me  the  coroner  at  the  time  of your  response,  about  the  release  or  the 
publication of your response by the Chief Coroner. 

9 

Date: 

Signed:

Responses

4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Secretary of State for Levelling Up Housing and Communities and Department (PDF)
Rt Hon Michael Gove MP   
Secretary of State for Levelling Up, Housing and 
Communities    
Minister for Intergovernmental Relations   
2 Marsham Street  
London 
SW1P 4DF 

Rt Hon Steve Barclay MP  
Secretary of State for Health and Social Care 
Minister for Intergovernmental Relations   
39 Victoria Street 
London 
SW1H 0EU 

Joanne Kearsley 
Senior Coroner for the Coroner Area of Manchester North 
HM Coroner's Court 
Floors 2 and 3 
Newgate House 
Rochdale 
OL16 1AT 

Dear Joanne, 

13 January 2023 

RESPONSE TO PREVENT FUTURE DEATHS REPORT: INVESTIGATION AND INQUEST INTO THE 
DEATH OF AWAAB ISHAK 

Awaab  Ishak’s  death  was  a  tragedy  that  should  never  have  occurred.  People  across  the  country  were 
horrified to hear about the terrible circumstances that led to it. Awaab’s case has thrown into sharp relief the 
need  for renewed  action  to  ensure that  every  landlord  in the  country makes certain that their tenants  are 
housed  in  decent  homes,  and  they  are  treated  with  dignity  and  fairness.  It  is  my  (Secretary  of  State  for 
Levelling  Up,  Housing  and  Communities)  relentless focus  to  restore the  right  of  everyone  in this  country, 
whatever their race or cultural background, to live somewhere warm, decent, safe and secure. 

On behalf of the Department for Levelling Up, Housing and Communities (“DLUHC”) and the Department of 
Health and Social Care (“DHSC”) we now want to outline our response to the Regulation 28 Report to Prevent 
Future Deaths concerning the death of Awaab Ishak (“the Report”), sent on 16 November 2022.  

The  Coroner’s  Report  followed  the  investigation  and  the  inquest  into  the  death  of  Awaab  Ishak  that 
commenced on 27 December 2020 and concluded on 15 November 2022. The conclusion of the inquest was 
that Awaab Ishak died as a result of a severe respiratory condition due to prolonged exposure to mould in 
his home environment. Action to treat and prevent the mould, was not taken. His respiratory condition led to 
a  respiratory  arrest.  The  medical  advice  given  to  his  parents  led  to  Awaab  receiving  sub-optimal  airway 
ventilation which was unable to prevent his cardiac arrest.  

In  providing  this  response  to  the  Report,  we  offer  our  sincere  condolences  to  Awaab  Ishak’s  family  and 
emphasise the Government’s commitment to addressing the matters of concern raised by the Coroner. 

The matters of concern identified in the Report are as follows: 

1. The 2006 document, "A Decent Home: Definition and Guidance for Implementation" does not give
any consideration to the issue of damp and mould. Nor does it provide any guidance as to the need
for a property to be adequately ventilated.

 2.  The HHSRS data sheet relating to damp and mould, is used to calculate risks of the incident and the 
spread of harm is not reflective of the current known risks of damp and mould and harm to health.  
3.  There was no evidence that up-to-date relevant health information pertaining to the risks of damp and 

mould was easily accessible to the housing sector.  

4.  The evidence  highlighted  a  "policy"  amongst  the  housing  associations,  in cases  where a  disrepair 
claim  has  been  brought  of  waiting  for  agreement  from  the  claimant  (or  their  legal  representative) 
before rectifying any recognised disrepair.  

5.  The private landlord sector does not have access to the Housing Ombudsman for their complaints to 

be investigated independently. 

Our responses to the matters of concern are set out below in turn.  

First  matter  of  concern:  The  2006  document,  "A  Decent  Home:  Definition  and  Guidance  for 
Implementation" does not give any consideration to the issue of damp and mould. Nor does it provide 
any guidance as to the need for a property to be adequately ventilated.  

We agree this is a matter of concern. Damp and mould can have a serious impact on the health of tenants, 
and it is unacceptable for anyone to have to live in such conditions. While the requirement to deal with them 
is implicit in the current Decent Homes Standard (“DHS”), it is clear that the review of the standards which is 
currently underway is necessary. 

The DHS, which was introduced in 2001 and last updated in 2006, plays a key role in providing a minimum 
quality  standard  that  social  homes  must  meet.1 The  DHS  sets  out  four  criteria for  evaluating  decency  –  it 
requires that homes are free of serious hazards (criterion A), are in a reasonable state of repair (criterion B), 
have  reasonably  modern  facilities  and  services  such  as  kitchens  and  bathrooms  (criterion  C),  and  have 
efficient  heating  and  effective  insulation  (criterion  D).  The  Regulator  of  Social  Housing  (“the  regulator”) 
requires that social rented homes are maintained by landlords to at least the quality set out by the DHS.2 
Good progress has been made on ensuring that social rented homes meet the DHS. 

The current DHS does not explicitly mention damp and mould but it is covered by the Housing Health and 
Safety  Rating  System  (“HHSRS”).  Criterion  A  of  the  DHS  states  that  a  home  should  meet  the  statutory 
minimum  standard  for  housing;  that  is,  being  free  of  category  1  hazards  as  defined  by  the  HHSRS.  The 
HHSRS includes damp and associated mould as a hazard to be considered in assessment.  

We are reviewing the 3.4extent to which the current DHS is the right ask of the social housing sector today; 
to consider the case for change; and to assess the strategic, economic and management case for different 
criteria. Part 1 of the Review concluded in Autumn 2021. Feedback from part 1 of the DHS review made it 
clear that we need updates. Ventilation was one of the areas highlighted and considered as part of criterion 
B (reasonable state of repair) and will form a key element of part 2 of the DHS Review. 

We engaged with the sector on part 2 of the DHS review in 2021, including a series of roundtables. We have 
also worked towards introducing a DHS in the private rented sector, on which a formal consultation ran in the 
Autumn of 2022. We are committed to continuing the DHS review and will set out next steps on this in due 
course. 

On 19 November 2022, I (the Secretary of State for Levelling Up, Housing and Communities) wrote to all 
providers of social housing in England5, drawing attention to your Report, and underscoring my expectation 

1 https://www.gov.uk/government/publications/a-decent-home-definition-and-guidance 
2 In some instances, the Regulator of Social Housing will grant exemptions for social landlords meeting the DHS. This 
is outlined in the Regulator’s Home Standard (2.1.1): 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/914576/Home_Sta
ndard_2015.pdf  
3 https://www.gov.uk/government/publications/the-charter-for-social-housing-residents-social-housing-white-paper 
4 https://www.gov.uk/guidance/decent-homes-standard-review 
5 https://www.gov.uk/government/publications/secretary-of-state-calls-for-action-on-housing-conditions 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 that it would be read in full and the lessons absorbed. I also set out my expectations, not only that all social 
homes must meet the DHS, but that in light of the tragic case of Awaab Ishak that I expected providers to go 
further than the letter of the Standard and have particular regard to damp and mould. Damp and mould are 
not  ‘lifestyle  issues’  as  the  Housing  Ombudsman  Service  underscored  recently.  A  copy  of  that  letter  is 
attached. 

We are also taking more immediate action to ensure landlords understand the risks of damp and mould and 
act  swiftly  when  necessary.  Following  the  Manchester  Evening  News  and  Shelter  campaign  for  ‘Awaab’s 
Law’, we will table an amendment to the Social Housing Regulation Bill relating to hazards in social homes. 

Our intention, subject to further discussion with the representatives of Awaab’s family, is to commit me (the 
Secretary  of  State  for  Levelling  Up,  Housing  and  Communities)  to  publishing  a  policy  statement  on 
approaches to tackling serious hazards (including damp and mould) in the social rented sector. The policy 
statement would specify time limits which landlords must meet regarding investigating hazards and acting 
where there are health concerns. I intend to direct the Regulator of Social Housing to implement the approach 
set out in this new policy statement in its standards. If this amendment is approved by Parliament we will 
implement any new measures as soon as possible and within six months of Royal Assent of the Bill. 

Second matter of concern: The HHSRS data sheet relating to damp and mould, is used to calculate 
risks of the incident and the spread of harm is not reflective of the current known risks of damp and 
mould and harm to health.  

We  agree  this  is  a  matter  of  concern.  Our  current  review  of  the  housing  health  and  safety  rating  system 
(“HHSRS”) will support a better understanding of the known risks of damp and mould to health. 

The HHSRS is a risk-based evaluation tool to help local authorities identify and protect against potential risks 
and hazards to health and safety from any deficiencies identified in dwellings.6 It was introduced under the 
Housing Act 2004 and applies to residential properties in England and Wales. The HHSRS does not set out 
minimum standards. It is concerned with avoiding or, at the very least, minimising potential hazards. This 
means that landlords should review conditions regularly to try to see where and how their properties can be 
improved and made safer.  

HHSRS inspections are conducted by trained assessors who will look for any risk of harm to an actual or 
potential occupier of a dwelling, which results from any deficiency that can give rise to a hazard. They judge 
the severity of the risk by assessing two things: the likelihood of an occurrence that could cause harm over 
the next twelve months, and the range of harms that could result. 

The  HHSRS  review  follows  an  initial  scoping  exercise  that  concluded  in  2019,  where  landlords,  tenants, 
agents, local authorities and academics told us they appreciated the link the HHSRS makes between housing 
and  health  and  how  it  allows  individual  properties  to  be  assessed  on  their  merits,  but  that  they  found  it 
complicated and inefficient to use. Ministers decided that work should be undertaken to clarify and modernise 
the HHSRS assessment and consider whether some hazard profiles could be removed or combined and to 
improve the guidance given to landlords and tenants.  

As such the full review has focussed on the primary issues raised in the scoping review, around making the 
tool easier to use, and updating the range of harms was not in scope.  

Our existing review will go some way to addressing the concern noted. Current research is being used to 
update estimates on the likelihood of harm due to dampness and mould alongside other hazards, and more 
broadly  the  review  will  improve  the  HHSRS  to make  it  more  up  to  date  (including  updated  guidance  and 
information on the health effects of damp and mould). It will make the tool easier for landlords and tenants to 
understand, easier for local authorities to use and better connected to other legislation. The review is nearing 
completion and the Government will publish a summary of the findings and set out next steps by the spring. 

6 https://www.gov.uk/government/publications/housing-health-and-safety-rating-system-guidance-for-landlords-and-
property-related-professionals  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Alongside  this  work  already  underway  as  part  of  the  HHSRS  review,  we  are  also  exploring  other  options 
focussed on addressing damp and mould, including the merits of a standalone damp and mould standard. 
We will consider these carefully and set out any further steps in due course. 

Third matter of concern: There was no evidence that up-to-date relevant health information 
pertaining to the risks of damp and mould was easily accessible to the housing sector.  

We agree this is a matter of concern. It is crucial that the housing sector has the full access to relevant and 
up-to-date information, including in particular on the health risks of damp and mould. The sector must be able 
to deliver services effectively for its residents. 

A number of documents on the health risks of damp and mould have been produced by the government, 
other  public  sector  bodies  and  housing  providers.  This  material  varies  in  its  level  of  detail,  quality  and 
accessibility, and there is a specific gap in guidance tailored to the housing sector.  

The  Department  of  Health  and  Social  Care  (DHSC),  with  the  Department  for  Levelling  Up,  Housing  and 
Communities (DLUHC), will lead a rapid review of existing guidance on the health impacts of damp and mould 
in homes, and then – engaging widely with interested parties – develop new consolidated guidance tailored 
to the housing sector. We will publish this new guidance by the summer. DHSC will lead this process and 
contribute  expertise  on  the  relevant  health  impacts,  working  closely  with  the  UK  Health  Security  Agency 
(“UKHSA”).  DLUHC  will  contribute  its  expertise  on  the  needs  of  the  housing  sector  and  how  best  to 
disseminate guidance to housing providers and tenants. 

Once completed, I (Secretary of State for Levelling Up, Housing and Communities) will write to social housing 
providers and local authorities to highlight the new guidance. I (Secretary of State for Levelling Up, Housing 
and  Communities)  will  also  make  sure  that  it  is  available  for  landlords  and  tenants,  working  closely  with 
stakeholders  to  ensure  it  is  widely  available,  including  in  the  future  ensuring  this  is  accessible  for  private 
landlords via the Privately Rented Property Portal.  

While  components  of  the  guidance  will  necessarily  be  technical  in  nature  and  directed  at  housing 
practitioners, we will ensure that its key messages on the need to understand the risks posed by damp and 
mould  and  the  need  to  act  appropriately  and  swiftly  are  packaged  and  provided  in  clear  and  accessible 
language for all. 

Fourth matter of concern: The evidence highlighted a "policy" amongst the housing associations, in 
cases where a disrepair claim has been brought of waiting for agreement from the claimant (or their 
legal representative) before rectifying any recognised disrepair.  

We agree this is a matter of concern. While the policies which Housing Associations set for disputes are not 
of course controlled by the Government, the ‘policy’ highlighted in Awaab Ishak’s case as a matter of concern 
is wrong. In Awaab Ishak’s case, the legal proceedings by Awaab’s family with respect to mould led to the 
landlord slowing down its response to the disrepair.  

Housing associations should take rapid action to address residents' concerns. On 19 November 2022, I (the 
Secretary of State for Levelling Up, Housing and Communities) wrote to all providers of social housing setting 
out my  expectation that “where  people complain about  damp and mould,  you must  listen;  where  you  find 
them, you must take prompt action. To keep tenants safe, you must not hide behind legal process”. 

The  Housing  Ombudsman’s  Guidance  for  Pre  Action-Protocol  for  Housing  Condition  Claims  and  Service 
Complaints stresses the importance of landlords inspecting properties as soon as a claim is raised and to 
completing the repairs needed as soon as is practicable.7 The guidance is clear that if a landlord receives 

7 https://www.housing-ombudsman.org.uk/landlords-info/guidance-notes/guidance-on-pre-action-protocol-for-housing-
conditions-claims-and-service-complaints/ 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 correspondence initiating the Pre-Action Protocol, it is important that they do not disengage from either their 
internal complaints procedure or the repair issue itself. 

Since the death of Awaab Ishak, I (the Secretary of State for Levelling Up, Housing and Communities) have 
also written to leading legal bodies requesting their help directing social tenants with concerns about their 
housing to the Housing Ombudsman and making clear that it was wrong of the landlord in Awaab Ishak’s 
case to let the intimation of legal proceedings get in the way of doing the right thing. Access to the law is a 
vital right for all residents, but legal proceedings are adversarial and can be costly and time-consuming for 
residents. A copy of that letter is attached. 

On  29  November  2022  the  Housing  Ombudsman  also  wrote  to  all  landlord  members  outlining  clearly  his 
expectations and the role the Housing Ombudsman Service (HOS) can play in resolving landlord and tenant 
disputes.8 

Fifth  matter  of  concern:  The  private  landlord  sector  does  not  have  access  to  the  Housing 
Ombudsman for their complaints to be investigated independently. 

We agree this is a matter of concern. Everyone has a right to safe and decent housing, and it is important 
that private tenants should be able to challenge poor practice and standards in their homes. 

The Government announced plans to introduce a new Private Rented Sector Landlord Ombudsman in the A 
Fairer Private Rented Sector White Paper.9 The proposal is for all private landlords in England to be required 
to be members of this Ombudsman. This will ensure that all tenants, regardless of whether they rent socially 
or privately, have access to redress where they have a legitimate complaint about their home. 

The new Ombudsman will help both tenants and landlords better understand their rights and obligations and 
will allow for earlier and quicker resolution of complaints. This will reduce the need to escalate issues to court 
and untimely evictions which can be more costly to both landlords and tenants. 

Our  intention  is  to  create  the  new  Private  Rented  Sector  Landlord  Ombudsman  through  the  upcoming 
Renters Reform Bill. We are committed to bringing forward legislation on this, and our wider reform package, 
in this Parliament. If the legislation is passed, we will seek to establish an Ombudsman as soon as practical 
and in tandem with our wider reforms.  

Other Government actions of relevance  

As set out above, in November, I (Secretary of State for Levelling Up, Housing and Communities) wrote to 
all providers of social housing to make clear my expectation that complaints about damp and mould are taken 
seriously,  and  that  swift  action  must  be  taken  to  rectify  issues  of  damp  and  mould.  I  also  wrote  to  Local 
Authority Chief Executives and council leaders setting out my expectation that they will take action to resolve 
poor housing conditions in their area and directing them to provide information on current housing conditions 
to the department. Local authorities who do not hold this information were asked to explain why.  

In  November  the  Regulator  of  Social  Housing  wrote  to  chief  executives  of  registered  providers  of  social 
housing  to  highlight  landlords’  responsibility  to  take  action  to  protect  tenants  from  hazardous  damp  and 
mould, and to request information on the extent of damp and mould issues in their homes.10  

I  have  suspended  £1million  of  funding  to  Rochdale  Boroughwide  Housing  that  was  allocated  under  the 
Affordable Homes Programme 2021-2026, until they can demonstrate that their stock is fit for purpose and 

8 https://www.housing-ombudsman.org.uk/wp-content/uploads/2022/11/Open-letter-to-member-landlords-November-
2022.pdf 
9 https://www.gov.uk/government/publications/a-fairer-private-rented-sector  
10 https://www.gov.uk/government/publications/letters-to-registered-providers-about-damp-and-mould 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 does not pose any risks to tenants. I also announced that other providers who are subject to a regulatory 
notice will be prevented from bidding for new funding through the Affordable Homes Programme.11 

Government has awarded a share of £14 million for seven areas with high numbers of poor privately rented 
homes to crack down on rogue landlords and test new approaches to driving up standards. 

Conclusion 

We hope that this response has addressed the concerns raised in the Report and has made clear how 
seriously the Government has taken this tragic case of Awaab Ishak’s death. If you require any further 
information or clarification, please let us know and we will do our best to provide this.  

Thank you for your letter and report. 

Yours ever, 

Rt Hon Michael Gove MP 

Rt Hon Steven Barclay MP 

Secretary of State for Levelling Up, Housing 
and Communities   
Minister for Intergovernmental Relations  

Secretary of State for Health and Social Care 

11 https://www.gov.uk/government/news/government-to-block-failing-social-housing-providers-from-new-housing-
funding#:~:text=Rochdale%20Boroughwide%20Housing%20(RBH)%20will,it%20is%20a%20responsible%20landlord.
Response from Secretary of State for Levelling Up Housing and Communities Letter to All P (PDF)
Rt Hon Michael Gove MP 
Secretary of State for Levelling up Housing & 
Communities  
Minister for Intergovernmental Relations 

Department for Levelling Up, Housing and 
Communities 
4th Floor, Fry Building 
2 Marsham Street 
London 
SW1P 4DF 

19 November 2022 

To: All providers of social housing 

ENSURING QUALITY IN SOCIAL HOUSING 

The tragic case of Awaab Ishak, who died at two years old as a direct result of mould in his family 
home, has rightly shocked people across the country. This is an appalling case of the utmost gravity, 
and it is abhorrent that anyone should have to live in such conditions in Britain today.  

As I said in Parliament this week: every single person in this country, irrespective of where they are 
from, what they do, or how much money they earn, deserves to live in a home that is decent, safe 
and secure. I expect those who hold the high responsibility of managing people’s homes to ensure 
that no family experiences such a tragedy again.  

Together, we must raise the bar dramatically on the quality of social housing and empower tenants 
so that their voices are truly heard. I want to be clear about what this must mean in relation to damp 
and mould, as I have been made aware of many cases where this has gone unaddressed for far too 
long and am concerned that they are not treated with sufficient seriousness. 

Treating damp and mould seriously 

The coroner’s report into Awaab’s death is a litany of failure. As housing providers, I expect you to 
read it in full and absorb its lessons. All social homes must meet the Decent Homes Standard; you 
must be aware of any that do not and undertake rapid remedial works. However, in light of this case 
I expect you to go further than the letter of the Standard and  have particular regard to damp and 
mould.1 Damp and mould are not ‘lifestyle issues’ as the Housing Ombudsman Service underscored 
last year. Where people complain about damp and mould, you must listen; where you find them, 
you must take prompt action. To keep tenants safe, you must not hide behind legal process. 

It is vital as we go into a challenging winter that you know the extent of damp and mould issues in 
your  stock  and  that  these  are  being  addressed.  To  that  end,  I  expect  you  to  be  undertaking 
assessments of: 

1 Specifically, as well as category 1 damp and mould hazards, to have regard to and take action on high scoring 
(bands D and E) category 2 damp and mould hazards, as outlined in the relevant guidance: 
https://www.gov.uk/government/publications/housing-health-and-safety-rating-system-enforcement-guidance-housing-
conditions 

 
 
 
 
 
 
  
 
 
 
 •  damp and mould issues affecting your properties, including the prevalence of category 1 and 

• 

2 damp and mould hazards; 
the action you have identified that may need to be taken in relation to damp and mould issues 
affecting your properties. 

The Regulator of Social Housing will be writing to you imminently on this and you should respond 
promptly. You should also self-refer to the Regulator of Social Housing should you become aware 
through those assessments, or other means, that you may be in breach of its regulatory standards.  

Taking responsibility 

I am more determined than ever to deliver our drastic reforms to the housing sector, protecting the 
rights of tenants and ensuring social landlords do not put people’s lives and livelihoods at risk. Our 
Social Housing Regulation Bill will enable a rigorous new regime that holds all landlords to account 
for the decency of their homes and the service they provide. The Regulator of Social Housing will 
proactively  inspect  landlords  –  and  will  have  the  power to  issue  unlimited  fines. It  will be  able to 
intervene in those cases where tenants’ lives are being put at risk because landlords are dragging 
their  feet  in actioning repairs.  And  in  the  very  worst  cases,  it  will  have  the  power to  instruct  that 
properties are brought under new management.  

We are bringing in these changes to rebalance the relationship between residents and landlords by 
enhancing  the  current  system  of  regulation  and  redress,  but  there  is  already  a  well-recognised 
minimum  quality  standard,  the  Decent  Homes  Standard,  and  clear  guidance  from  the  Housing 
Ombudsman Service on how complaints should be handled.  Landlords must ensure their homes 
meet this Standard and handle complaints in line with the Ombudsman’s guidance.  

It is vital that we learn from the mistakes that led to the tragic death of Awaab, and I look forward to 
working collaboratively with you to improve standards. I firmly believe in the right of everyone to feel 
safe in the place where they and their loved ones sleep at night. I hope you will join me in doubling 
down on our efforts to provide the high-quality social housing this country deserves. 

Yours, 

Rt Hon Michael Gove MP 
Secretary of State for Levelling Up, Housing and Communities 
Minister for Intergovernmental Relations
Response from Secretary of State for Levelling Up Housing and Communities Letter to Legal (PDF)
Rt Hon Michael Gove MP   
Secretary of State for Levelling Up, Housing and 
Communities    
Minister for Intergovernmental Relations   
2 Marsham Street  
London SW1P 4DF  

 28 December 2022 

Chartered Institute of Legal Executives (CILEX) 
CILEX Regulation 
Law Society 
Bar Council 
Solicitors Regulation Authority 
Bar Standards Board 
Office for Legal Complaints 
Legal Services Board 
Law Works 
Shelter 
Citizens Advice Bureau 
Housing Law Practitioners Association 

Dear legal representatives, 

HELPING SOCIAL HOUSING RESIDENTS 

The tragic case of Awaab Ishak, who died at two years old as a direct result of mould in his family 
home, has rightly shocked people across the country. This is an appalling case of the utmost gravity, 
and it is abhorrent that anyone should have to live in such conditions in Britain today. 

I am writing to ask for your help. I know how important the work you and your colleagues do is for 
people  seeking  justice.  But  I  would  like  to  emphasise  the  importance  of  directing  social  housing 
tenants with concerns about their housing to the Social Housing Ombudsman. The Ombudsman is 
there to help people when their landlord fails to deal with complaints properly. While many landlords 
provide a good service to residents, unfortunately problems such as those experienced by the Ishak 
family are not uncommon in social housing.  

The  Ombudsman  investigates  the  circumstances  of  each  individual  case  independently  and 
impartially. If the Ombudsman upholds a complaint following investigation, it has powers to order 
remedies including that landlords make necessary repairs, apologise and/or pay compensation. This 
can help families to overcome the distress and indignity of living in such terrible conditions. 

We have made it quicker and easier to access the Ombudsman.  From 1 October 2022, changes 
introduced by the Building Safety Act, mean that residents will no longer have to refer their complaint 
to a designated person, such as an MP, or wait eight weeks before the Ombudsman can consider 
their complaint. 

All  social  housing  residents  should  know  about  the  Ombudsman,  which  is  free  to  use.  Our 
nationwide campaign, ‘Make Things Right’, which has reached millions of social housing residents, 
is designed to inform them of how they can make a complaint and access the Ombudsman.  

I would like your assistance in ensuring that you and your members are proactive in directing people 
to the Ombudsman, whose website can be found at www.housing-ombudsman.org.uk. 

 
  
 
 
 
  
 
 
 
 
 The Government recommends that people contact the Ombudsman first to receive advice about the 
best course of action. In some instances, the Ombudsman may recommend the use of the courts, 
or tribunal.  

Access to the law is a vital right for all residents, and the good work you do helps settle issues which 
may  not  otherwise  be  resolved  between  landlords  and  residents,  but  it  can  be  costly  and  time-
consuming. In the case of Awaab Ishak, the legal proceedings led to the landlord slowing down its 
response to the disrepair. There is no requirement for the landlord to do this and it was wrong of the 
landlord to let legal proceedings get in the way of doing the right thing.  

It is vital that we learn from Awaab’s death. I firmly believe in the right of everyone to feel safe in the 
place where they and their loved ones sleep at night. I hope you will  support me in our efforts to 
help residents receive the high-quality social housing that they deserve. 

With every good wish, 

RT HON MICHAEL GOVE MP  
Secretary of State for Levelling Up, Housing and Communities   
and Minister for Intergovernmental Relations
Response from Secretary of State for Levelling Up Housing and Communities Letter to Local (PDF)
Rt Hon Michael Gove MP 
Secretary of State for Levelling up Housing & 
Communities  
Minister for Intergovernmental Relations 

Department for Levelling Up, Housing and 
Communities 
4th Floor, Fry Building 
2 Marsham Street 
London 
SW1P 4DF 

19 November 2022 

Dear Local Authority Chief Executive and council leaders, 

HOUSING STANDARDS IN RENTED PROPERITES IN ENGLAND 

The tragedy of Awaab Ishak, who died at two years old as a direct result of mould in his family home, 
has highlighted the urgent need to ensure a decent standard of properties for tenants in all sectors. 

I  know  you  will  join  me  in  mourning  this  avoidable  loss.  I  also  know,  from  previous  experience,  that 
councils and authorities across the country are already determined to improve housing standards. That 
is why I am confident you will all be as focussed as my department is on ensuring that no family ever has 
to experience such a tragedy again. In 21st century Britain, this should not be a high aspiration. 

I have today written to social housing providers on this crucial matter. All of us – including my department 
– need to deliver our responsibility to people living in poor quality housing. That is why I am writing to 
you to request you do everything in your power to prioritise the improvement of housing conditions for 
the  millions  of  private  and  social  tenants,  in  line  with  existing  duties  in  the  Housing  Act  2004.  This 
becomes  ever  more  urgent  as  we  go  into  winter  with  a  cost  of  living  and  energy  crisis,  which  may 
exacerbate damp and mould conditions in some homes.  

As you will be aware, local housing authorities have a duty under the Housing Act 2004 (“the Act”) to 
keep housing conditions in their area under review with a view to identifying any action that may need to 
be taken by them under the Act (section 3(1)). 

Treating damp and mould seriously 

Having considered it necessary and urgent to ensure that, as we go into a challenging winter, damp and 
mould  issues  are  being  addressed,  I  now  direct,  under  section  3(3)  of  the  Act,  that  all  local  housing 
authorities in carrying out their duty to review housing conditions in their area must: 

•  have particular regard to high scoring (bands D and E) category 2 damp and mould hazards, as 
outlined  in  the  guidance  ‘Housing  health  and  safety  rating  system  (HHSRS)  enforcement 
guidance: housing conditions1’  

•  supply the department with an assessment of damp and mould issues affecting privately rented 
properties in your area, including the prevalence of category 1 and 2 damp and mould hazards; 
and 

1 https://www.gov.uk/government/publications/housing-health-and-safety-rating-system-enforcement-guidance-
housing-conditions 

 
 
 
 
 
 
 •  supply the department with an assessment of action you have identified that may need to be taken 

in relation to damp and mould issues affecting privately rented properties in your area. 

In addition, pursuant to your duties under section 3(3) of the Act, I would like you to provide the following 
data covering your last three 12 monthly reporting periods for privately rented properties in your area: 

•  how many damp and mould hazards you have remediated, compared to your assessment of the 

prevalence of these hazards; 

•  how many times you have taken enforcement action to remedy damp and mould hazards and the 

form this has taken; 

•  how many civil penalty notices have been issued in relation to non-compliance with enforcement 

action over damp and mould hazards; and 

•  how many prosecutions have been successfully pursued in relation to damp and mould hazards. 

If you have not collected this information, please explain why. 

Finally, I would also like you to set out how you are prioritising enforcement of housing standards more 
generally  in  your  authority,  across  all  tenures,  including  what  plans  you  have  to  ensure  adequate 
enforcement capacity to drive up standards in the private rented sector.  

Alongside this, I have asked social housing providers to make an assessment of their properties and the 
Regulator of Social Housing will also be writing to them shortly on this matter.  

I would like an initial response by the end of the month – this should set out how you are prioritising this 
work and any other initial information you can provide. I would then like the full response by 27 January 
at the latest. My officials will work with the Local Government Association and local authorities to agree 
the process and format for these responses in the coming days. Any questions in the meantime can be 
directed to housingstandards@levellingup.gov.uk. My department will review these returns and may ask 
for  further  information.  We  may  also  periodically  publish  the  responses,  or  a  summary,  to  improve 
transparency on this important issue. I have focussed here largely on damp and mould to make quick 
progress on this important area during the winter months, but reserve the right to make further directions 
and requests in relation to wider standards in the near future as the department deems necessary. 

I would like to take this opportunity to thank you for the important work that you do in your local areas to 
improve housing standards for tenants. It is vital that we all learn from the events that led to the tragic 
death of Awaab, and my officials and I look forward to working collaboratively with you to improve 
standards for renters across the country and across all tenures.  

With every good wish, 

Rt Hon Michael Gove MP 
Secretary of State for Levelling Up, Housing and Communities 
Minister for Intergovernmental Relations

Related reports

Other reports by Joanne Kearsley

See all →

More reports categorised “Child Death (from 2015)”

See all →

Track Child Death (from 2015)

See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.