Guidance needed for the inclusion of air pollution on death certificates

In an opinion piece in the British Medical Journal, calls have been made for national guidance on the inclusion of air pollution on death certificates for clinicians.

The article was jointly authored by Laura-Jane Smith, a consultant respiratory physician in south London and part of the Healthy Air Coalition UK; Mike Tomson, retired GP, director of Greener Practice, and a trustee of the Centre for Sustainable Healthcare; and Kath Brown, a GP in Cornwall, director of Greener Practice and a Global Action Plan Clean Air champion.

It is ten years, they point out, since Ella Adoo-Kissi-Debrah died and three years since she became the first person to have air pollution listed on her death certificate. To this day she remains the only one.

The fact is, that a great deal of effort and research – not to mention two inquests – went into securing that recognition, which is possibly why Ella remains the exception.

The writers point out that this anomaly was often used to counter Sadiq Khan’s claims about the effects of air pollution in the run-up to the ULEZ expansion. ‘Air quality hasn’t killed thousands of Londoners,’ they would crow. ‘It’s killed one’.

The writers explain: ‘Death certificates serve multiple purposes: they explain the cause of death to the family, allow them to register the death, and are a public record accessed by researchers, lawyers, and national bodies. It is important that a major source of preventable death should appear in our national statistics as this underpins decision making. Death certification is a key way in which data on cause of death are collected.

‘Government advice is provided on the inclusion of smoking, alcohol, and occupational exposures, but not on when to include air pollution.’

Medical campaign groups, of which the authors are members, have previously written to coroners about this issue and received a variety of replies, most of which seem to demonstrate a lack of familiarity with the air quality problem.

Another problem of attributing air pollution as a cause of death is that it is not included on the list of ‘natural causes of death’ as laid down by the Royal College of Pathologists. As such, coroners would have to open an investigation and inquest.

‘It is illogical that death from tobacco smoke exposure is considered a natural cause,’ the writers say, ‘whereas death from fossil fuel smoke exposure is not. Smoking and air pollution are both causes of unnatural death which should be treated in the same way on death certificates.’

They are calling for:

• National guidance on the inclusion of air pollution on death certificates for clinicians
• A review of when inquests should be triggered or whether the RCPath list of “natural” causes of death should be amended
• Education for coroners, medical examiners, and healthcare professionals on the significant contribution of air pollution to deaths.

They conclude: ‘Only by counting the consequences can we expose the harms from air pollution and create the widespread awareness needed to bring about policy change and protect the right of every person to breathe clean air.’