The inquest into the death of 2-year-old Awaab Ishak concluded today (15 November 2022), with the Coroner finding Awaab died as a result of a severe respiratory condition due to prolonged exposure to mould in his home environment.
The inquest was heard over 7 days at North Manchester Coroner’s Court in front of HM Senior Coroner Ms Joanne Kearsley.
Awaab sadly passed away on 21 December 2020, aged just two years old. He lived at home with his parents in a housing estate in Rochdale, managed by Rochdale Boroughwide Housing (RBH). Awaab’s parents had previously made complaints about the black mould present in the kitchen and bathroom and had also made requests for re-housing.
Over the weeks prior to his death, Awaab developed flu-like symptoms and had difficulty breathing. On 19 December 2020, he was taken to Rochdale Urgent Care Centre due to his difficulty breathing and was then transferred to Royal Oldham Hospital, where he was given supporting treatment and then discharged.
Awaab continued with difficulties at home and his breathing became worse, so his parents requested a GP and gave him medication. As his presentation was worsening, he was taken to Rochdale Urgent Care Centre on 21 December 2020, where he was found to be in respiratory failure. He was transferred to Royal Oldham Hospital where upon arrival he was in cardiac arrest and sadly was pronounced dead on the same day.
The Court heard how Awaab’s health visitor sent a letter to RBH in July 2020 supporting a request for the family to move due to damp and mould. She expressed her concern over Awaab living in the flat and highlighted the health issues that the mould could cause him.
The Coroner has found the cause of death was:
1a) Acute airway Oedema with severe granulomatous tracheobronchitis
1b) Environmental Mould Exposure
The inquest heard evidence from a number of experts, medical professionals, and staff at RBH.
Pathologist Dr Philip Lumb who carried out Awaab’s post-mortem told the Court that Awaab’s throat was swollen to a degree that would compromise his breathing. His windpipe and other airways were also swollen and congested. There was evidence of fungus in his blood and lungs, and exposure to fungi was the most plausible explanation for the inflammation.
The inquest also heard from Professor Malcolm Richardson, who is an expert on moulds and fungi and their effect on health. He examined the family’s flat 10 days after Awaab died and found “extensive mould” on the walls and ceilings of the bathroom and kitchen and also found mould in a cupboard in the bedroom. He told the Court that the flat would have been contaminated “for some considerable time”.
Rochdale Council building surveyor, Daniel McVey, inspected the property two days after Awaab’s death and told the Court that it was not fit for human habitation without repairs being carried out. Despite this, Awaab’s parents had to continue living in the flat following Awaab’s death following unsuccessful requests for rehousing, despite Awaab’s mother being pregnant at the time.
Richard Blakeway of the Housing Ombudsman for England told the Court that the law needs to be reinforced to compel landlords to address damp and mould problems, as the issue is not given the same legal standing as gas safety and legionella. He said that some social landlords have an “outdated, ineffective, sometimes dismissive” approach with an overemphasis on blaming the tenant’s lifestyle.
Nadia Khan, Director of Customer and Community at RBH, gave evidence around changes that have been made since Awaab’s death. Ms Khan gave evidence that with the benefit of hindsight, works would have been carried out at the family’s flat sooner. She said that this matter has been a “big learning experience for us to change things for the better”. RBH have no plans to knock down the estate, including the block where Awaab lived, but they have installed additional ventilation to the properties. The flat Awaab lived in did not have a window in the bathroom and the window in the kitchen led to a communal walk way.
Following a Pre-Inquest Review Hearing earlier this year, Manchester Evening News investigated other families at the same estate and their experiences of damp and mould. Following this, the Coroner directed Greater Manchester Police to cross reference their investigation with the Manchester Evening News reports and the Police documented a number of flats at the estate who also had damp and mould present in their properties.
The inquest also heard evidence from medical staff involved with Awaab’s care. Dr Marshall, the paediatric doctor who saw Awaab on the night of 19 December treated Awaab with a small dose of steroid and he was given an inhaler before discharge. Following guidance, Dr Marshall diagnosed Awaab with croup. Due to Covid rules at the time, only one parent was allowed to stay with Awaab and his mother, Aisha, was with him. She raised concerns about the damp and mould in the home to Dr Marshall and showed the doctor images on her phone. Dr Marshall admitted that she used Google Translate rather than a telephone translation service to say that Awaab should “go to hospital” if he struggled with his breathing again, but was not specific about going directly to Royal Oldham Hospital.
Northern Care Alliance NHS Foundation Trust (NCA), who run both Royal Oldham Hospital and Rochdale Urgent Care Centre, have admitted that Awaab would have not died at the time he did, on the balance of probabilities, if he had been admitted to Royal Oldham Hospital sooner. Dr Panasa, who carried out a review into the case for NCA, explained that Awaab would have been seen by additional staff with expertise to carry out specialist treatment if he was taken to Royal Oldham Hospital sooner.
Following the first two days of evidence, RBH made a number of admissions, including:
It is accepted that Awaab’s father reported he had found mould within the property in 2017 and may have been told by an RBH employee to paint over the area.
On 9 July 2020, RBH received a letter from Caroline Ridley (Health Visitor), supporting a request to move due to mould.
On 14 July 2020, members of the RBH repair team visited the property to undertake a disrepair report. The findings of the report concluded that the majority of the mould was caused by ‘lifestyle and bathing habits’. Having considered the evidence of Richard Blakeway (Housing Ombudsman), Professor Malcolm Richardson (Expert) and in conjunction with the report of Daniel McVey, RBH accept that its approach was inappropriate and it should have taken responsibility for the mould issues and undertaken a more proactive response.
On 12 June 2020, a letter of claim for disrepair was received by RBH from Anthony Hodari Solicitors, acting for Awaab’s father. On 29 July 2020, RBH sent the disrepair report to Anthony Hodari Solicitors. It is accepted that in 2020, RBH had in place a policy that remedial works would not be undertaken unless RBH had the agreement of the claimant’s solicitor. It is accepted that as a landlord RBH retained the power to conduct repairs and there was no legal requirement to wait for the consent of the claimant’s solicitor before undertaking repairs.
It is accepted that RBH should have undertaken remedial works having found the mould in its inspection of the property on 14 July 2020.
It is accepted that no remedial works were undertaken by RBH after 14 July 2020 and before Awaab’s death on 21 December 2020.
It is accepted that various RBH teams were contacted and received further notifications about the mould from Awaab’s family during this time.
It is accepted that in 2020 the customer relationship management system (CRM) was not being fully and consistently used by RBH and not all contacts and/or communications were being logged on the CRM system, resulting in some information relating to Awaab and his family not being immediately available to RBH staff when looking up their files.
Admissions were also made by NCA, including:
The medical team at Royal Oldham Hospital should have admitted Awaab to the children’s unit for a longer period of observation on 20 December 2020 to better assess the trajectory of his respiratory effect.
On 21 December 2020, the children’s community nursing team should have advised the family to wait for an ambulance which would have brought Awaab directly to Royal Oldham Hospital. Had Awaab attended Royal Oldham Hospital, the delay in first going to Rochdale Urgent Care Centre would have been avoided; appropriate treatment would have been instigated earlier; and, on the balance of probabilities, Awaab would not have gone into respiratory arrest and subsequent cardiac arrest when he did.
The Coroner confirmed that she would be issuing a Prevention of Future Deaths report to the Minister for Housing and the Secretary of State for Health highlighting the concerns raised by this death. In addition she will be writing a letter to Rochdale Council and the NCA regarding the sharing of information between agencies and health related issues for the environment.
A statement was read by Kelly Darlington from Farleys Solicitors which can be viewed below
There has been a lot of interest in this case and we hope that this inquest will have a far-reaching effect for those with mould and damp in their properties. Richard Blakeway, of the Housing Ombudsman for England, gave evidence that landlords can place too much responsibility on the residents. It has been a difficult process for the family and they were asked personal questions, with what they feel to have racial undertones, about their bathing habits. RBH have now accepted that their conclusion that the majority of the mould was caused by lifestyle and bathing habits, was inappropriate.
Christian Weaver, Counsel for the family, said:
“Instead of Awaab’s parents preparing for his 4th birthday, they have had to sit through a gruelling inquest process and hear the multiple ways in which the very organisations supposed to take care of Awaab failed to do so.
“Awaab’s parents did everything within their powers to try and have the issues within their home fixed – however time and time again – their pleas were ignored. Awaab’s parents have shown remarkable dignity throughout the inquest process. Their only ask is that, once and for all, the conditions for those in social housing can be improved – particularly where damp and mould is concerned, and particularly where the occupiers of the homes are refugees and may not be as aware of systems and processes here in the UK. I hope that the findings arising out of this inquest play a significant role in helping achieve this.”