Dear Sir

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: Dr Phillip Barlow Assistant Coroner Southward Coroner’s Court 1 Tennis Street London SE1 1YD Litigation Group 102 Petty France Westminster London SW1H 9GL T 020 7210 3000 DX 123243, Westminster 12 www.gov.uk/gld Your ref: Inquest Our ref: 17 June 2021

- 2 - 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.

- 3 - 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

- 4 - 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

- 5 -
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

- 6 -

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:

- 7 -

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

- 8 - 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.

- 9 - 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;

- 10 - 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.

- 11 - 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.

- 12 -
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

- 13 -

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

- 14 - 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

- 15 -
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.

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.

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

Date: 16 June 2021

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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.

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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.

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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

City Hall, The Queen’s Walk, London, SE1 2AA ♦ ♦ london.gov.uk ♦

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.

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.

Page | 2

Dear Mr Barlov, 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 a5 Joint Honorary Secretary to Council Firstly, can convey Our condolences to the family friends of Ella_ was saddened to read of Ella'$ 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 35 the voice' of GPs on issues concered 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 a5 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 2 reply to vour Regulation 28 letter. would particularly like to thank Drs and Dr for 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 supported by the college's Climate Change Emergency Advisory Group which is jointly chaired by Dr land 3 former RCGP President Dr We also work Royal College of General Practitioners 30 Euston Square, London NWI 2FB rcgp org uk Patron: HRH The Duke of Edinburgh (1972-2021) Registered Charity Number 223106 and 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 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 broader approach to planetary change,it would incorporate elements regarding pollution: RCGP is supportive of the use of non-carbon transport In line with 3 change to our commercial policies, We emphasise electric modes of transport as well as where appropriate, supporting the use of bicycles, such a5 that arranged by our Wessex Faculty (see here for details) Finally; RCGP asan 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 if you have any questions, please do hesitate to contact me -

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.

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

b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case, the Royal College 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

7 ‘Future Midwife: standards of proficiency’, published November 2019

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 , Chief Medical Officer as part of a multi-agency meeting hosted by Dr on 1 June 2021. At that meeting, we agreed to share our responses with Professor and , 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.

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.

Dear Mr Barlow,

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

2

BTS 10 June 2021 2

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:

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.

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 need for a new clean air act” at the 2017 Summer Meeting.
- Short courses for health care professionals in relation to Occupational and Environmental Lung Disease in 2018 and 2021.
- 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

3

BTS 10 June 2021 3

- 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.

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.

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.

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 5-11 Theobalds Road London WC1X 8SH
-

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.

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 (Chief Medical Officer), (Chief Nursing Officer for England) and all the organisations who attended a multi-agency meeting hosted by Dr 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.

Dear Mr Barlow, RE: Report to Prevent Future Deaths, published Tuesday 20 April 2020 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 1 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 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 3 inequalities in vulnerability to COVID - as people with health conditions due to air pollution are more at risk of severe COVID complications.4 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 5 pilot can help to inform future training for health professionals. 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 6 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 Whitehouse & Grigg, 2021. Air pollution and children’s health: where next? BMJ Paediatrics Open 5 Global Action Plan. Healthcare resources 4 Travaglio et al., 2021. Links between air pollution and COVID-19 in England. Environ Pollut. 268(Pt A):115859 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 2 UN, 2019. Issue of human rights obligations relating to the enjoyment of a safe, clean, healthy and sustainable environment 1 Barlow, P., 2021. Report to prevent future deaths

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

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

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

17th June 2021

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

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.