Inside the case to prove air pollution contributed to death of nine-year-old Ella Adoo-Kissi-Debrah

“We’re exhausted. It feels emotional and it feels like there’s been a long hard-fought battle,” says Jocelyn Cockburn, a lawyer representing the family of Ella Adoo-Kissi-Debrah. “And I really have my thoughts with Rosamund and her children. This is their battle. This is the death of a loved child and sibling.”

In February 2013, Ella, a nine-year-old school child from south London, died after suffering a severe asthma attack. She had been admitted to hospital around 30 times in the three years prior as a result of her asthma. Since then, her mother Rosamund Adoo-Kissi-Debrah has been searching for answers.

Ms Cockburn tells The Independent: “Today Rosamund truly got the answer she’s been looking for, which is what was it that caused Ella’s death? I think the coroner’s ruling on that could not have been clearer. Excessive levels of air pollution contributed to her death. She has that answer now.”

Today, an inquest held at Southwark Coroner’s Court concluded that dangerous levels of air pollution contributed to Ella’s death. The landmark ruling means that Ella is the first person in the UK, and possibly the world, to have air pollution exposure listed as a cause of fatality on her death certificate.

Following the verdict, Ella’s mother Ms Adoo-Kissi-Debrah, a former school teacher-turned full-time campaigner, told reporters: “This was about my daughter, getting air pollution on the death certificate which we finally have. We’ve got the justice for her which she so deserves. But it’s also about other children, who are walking around cities with high levels of air pollution.”

Ella’s death was first subject to an inquest in September, 2014. At this inquest, Ella’s cause of death was recorded as acute respiratory failure caused by severe asthma, but the role of air pollution was not investigated.

By 2015, the impact of air pollution on people’s health had become more prominent in the media, bringing it to the attention of both Ms Cockburn and Ms Adoo-Kissi-Debrah.

“As a human rights lawyer, I felt there must be a basis for challenging the government to take action to reduce levels of air pollution, which affected me as someone suffering from asthma myself,” says Ms Cockburn.

“Rosamund came to me and we looked at what steps we’d need to take in order for her to get the answers she needed. And because she didn’t think the first inquest had provided an answer into Ella’s death, the obvious route to do this was to try to get a second inquest.”

To this aim, the women started to gather the evidence that might be needed for a second inquest.

This included building a picture of what pollution levels Ella was exposed to in her daily life. Ella and her family lived around 25 metres from the South Circular Road in Lewisham, south London. It was later revealed that air pollution from traffic on this road exceeded the annual legal limit constantly between 2006 and 2010.

“Eventually we got a report from Professor Sir Stephen Holgate, which really was like a lightbulb moment in showing the impact that air pollution had on Ella,” says Ms Cockburn.

In 2018, Professor Sir Stephen Holgate, a leading researcher of the impacts of air pollution on human health from the University of Southampton, produced a report for Ella’s family that linked her death to illegal air pollution levels in the area that she lived in.

Sir Stephen tells The Independent: “It’s a wonderful indication for Rosamund’s plight to have air pollution recognised as a contribution to her daughter’s death. I think it’s absolutely stunning because she’d been relentless in getting the evidence together.

“I was a small part of that and I was very pleased to be because I also believe air pollution contributed to her death in a significant way.”

By studying Ella’s medical records, Sir Stephen determined that Ella had a form of asthma that made her particularly sensitive to the air she breathed.

“She was an unusual little girl with asthma because she had what we call ‘hypersecretory asthma’. It just means the slightest irritation to her lung would lead to the outpouring of mucus,” he explained. “In a way, the very unpleasant episodes she had, 27 of them altogether that took her into hospital in two and half years, were the result of this.”

Sir Stephen was able to link Ella’s asthma episodes to air pollution by ruling out all the other typical leading causes of asthma in children.

These included allergies, of which Ella had none, and exposure to viruses. “She had one or two viruses but they never on a regular basis preceded these catastrophic events,” he said.

He added: “When I looked under the microscope at some of the airway tissue she had at death, I could see that the airways themselves were severely damaged. She had been breathing in an irritant substance.”

His findings eventually led the High Court to quash the results of the first inquest, and prompted the attorney general to announce a fresh inquest, says Ms Cockburn.

“And that’s what the last two weeks have been about,” she says. “They’ve been a public hearing of all the evidence relevant to Ella’s death.”

The second inquest into Ella’s death began on 30 November and lasted for 10 days. It saw striking testimony from Ms Adoo-Kissi-Debrah, who described her daughter as “incredibly well-liked” and the “centre of our world”.

Ms Adoo-Kissi-Debrah also told the inquest that she was not aware of the risks posed to Ella’s health by air pollution, and, if she had known, she would have moved home.

The inquest also saw further scientific evidence brought forward by Professor Jonathan Grigg, an expert in children’s respiratory health from Queen Mary, University of London.

Prof Grigg tells The Independent: “This verdict is in line with what the evidence has been telling us. It gives a clear face to this science that we all accept: that air pollution is causing deaths in the population.”

Evidence suggests that between 28,000 and 36,000 people will die each year as a result of air pollution in the UK. In his evidence, Prof Grigg showed that, at the time of Ella’s death, scientists already had a good understanding of the links between asthma and air pollution.

“When we talk about evidence, we’re not just talking about one research paper,” he says. “With epidemiological evidence, what you’re looking for is high-quality evidence from different sectors showing the same thing.”

By the time of Ella’s death, studies from different parts of the world had detailed the dangers of exposure to illegal air pollution. “By 2000, it was clear that we had a major health problem from air pollution,” he says.

This evidence helped to make the case that government agencies should have taken more stringent actions to tackle illegal levels of air pollution.

In his ruling, the coroner Philip Barlow said that Ella had been exposed to levels of two air pollutants, nitrogen dioxide (NO2) and particulate matter, in excess of the limits set by the World Health Organisation.

“Ella died of asthma contributed to by exposure to excessive air pollution,” he concluded. “There was a recognised failure to reduce the levels of NO2, which possibly contributed to her death.”

The landmark ruling should lead to more stringent action from the government to tackle air pollution, and more awareness of how the health risks it poses need to be made known to the public, says Sir Stephen.

“In reality, any young child with anything more than very mild asthma is going to be at risk of problems from air pollution.

“We need the government to start taking the air pollution measures more seriously. We need local authorities to provide greater granularity about what the local exposures of their population are. We need the GPs and hospitals to start drawing attention to air pollution as a serious risk to human health, like they do with obesity and diabetes.”

Ella’s case shows how there is currently a “disjoint” in scientific knowledge about the risks posed by air pollution and the awareness of the general public, says Ms Cockburn.

“It’s been recognised as a public health emergency, but almost in isolation to the human beings it affects,” she says. “And I think this case really links the two. I don’t think it’s going to be possible now to ignore the very real suffering that air pollution causes.”