Landmark air pollution decision in the Ella Roberta Adoo Kissi-Debrah case

On 16 December 2020, the London Inner South Coroner’s Court concluded its two-week inquest, led by coroner Philip Barlow concerning the death of nine-year-old Ella Roberta Adoo Kissi-Debrah in February 2013.

The coroner ruled that air pollution was a contributory factor in Ella’s death as a consequence of acute respiratory failure. Ella suffered with severe asthma in an area of south London exposed to levels of air pollution that exceeded EU limits.

This landmark decision follows the findings of a 2014 inquest, which found that “something in the air” may have triggered Ella’s acute respiratory failure, but otherwise focussed on her medical care. Ella’s mother, Rosamund Adoo Kissi-Debrah, launched a grassroots campaign in response. In May 2019, the High Court quashed the first inquest, ordering a fresh inquest in 2020 to examine the role of air pollution.

The inquest

The two-week long inquest took place in November and December 2020 and heard submissions from representatives and experts on behalf of the Department for Environment, Food and Rural Affairs (DEFRA), the Department for Transport, Department for Health and Social Care (DHSC), as well as the Greater London Authority and Lewisham London Borough Council. Professor Sir Stephen Holgate, a leading expert on air quality at the University of Southampton, submitted expert evidence on behalf of Ella’s family.

Prof Sir Holgate has worked with Rosamund Kissi-Debrah since 2015, producing a report in 2018, linking Ella’s death to the high levels of air pollution captured by a monitoring station near Ella’s home in south-east London. The levels of air pollution were found to continuously exceed the EU legal limits in the three years preceding Ella’s death. Prof Sir Holgate’s 2018 report was instrumental in quashing the 2014 inquest verdict and ordering the 2020 inquest. 

In particular, Ella’s condition was confirmed to be exacerbated by her living in the vicinity of London’s South Circular Road, where the traffic-induced air pollution is above-average “even for London”, according to Professor Paul Wilkinson of the London School of Tropical Diseases, who also submitted evidence at the inquest. According to Prof Sir Holgate, her condition worsened in the winter months of 2012 due to seasonal worsening of air pollution

Coroner Barlow affirmed that, in the period of 2010-2013, during which Ella’s illness developed, she had been exposed to nitrogen dioxide (NO2) and particulate matter (PM) levels in excess of the World Health Organisation (WHO) guidelines, and that the NO2 and PM pollution was principally caused by traffic emissions. Moreover, the State had failed to act against this air pollution, in order to bring it in line with legal limits imposed both in EU and domestic law. In conclusion, Ella’s death was recorded as “[…] asthma contributed to by exposure to excessive air pollution”.

In addition, Ella’s family argued that the Government’s failure to protect the public from such dangerous levels of air pollution constituted a breach of Article 2 of the European Convention on Human Rights, the right to life. However, the Court did not address this argument in its Record of Inquest.


Coroner Barlow’s decision is the first of its kind in the UK in finding that air pollution can act as a contributory factor in an individual’s death, against the background of the Government’s own estimate that between 28,000 and 36,000 deaths in the UK annually are caused by long-term exposure to air pollution.

The decision is therefore likely to increase the pressure on central and local Government to act on air pollution and set more progressive air quality targets, as well as impacting policies such as Low Traffic Neighbourhoods. In particular, the London Inner South Coroner’s Court affirmed the findings of Prof Sir Holgate, who during the inquest criticised DEFRA and DHSC for failing to work together on tackling air pollution.

Today’s judgment will be welcomed by air quality campaigners across the UK and beyond. However, victory for Ella’s family comes on the same day that the Supreme Court reversed the Court of Appeal’s decision to prevent the construction of a third runway at Heathrow Airport. Both decisions come in the context of renewed commitments by the Government to tackle air pollution, including, most recently, the Prime Minister’s promise to cut carbon emissions by 68% by 2030.

With thanks to Adel Msolly for his assistance with this blog.