He died after breathing in severe levels of mould in a one-bedroom Rochdale flat, eight days after his second birthday. Awaab Ishak suffered a cardiac arrest, brought on by respiratory failure. His home, which should have been a place of safety and sanctuary, poisoned his tiny body.
His parents, Faisal Abdullah and Aisha Amin, who came to the UK as asylum seekers from Sudan, had repeatedly complained to their landlord, Rochdale Boroughwide Housing (RBH), about mould in their property on the Freehold estate, and followed the advice they were given about tackling it.
Nearly two years on from Awaab's December 2020 death, an inquest has concluded he suffered a cardiac arrest due to respiratory failure, which had been caused by mould affecting his airway, in a poorly ventilated flat which an expert would describe as 'unfit for human habitation'. His family said, after the hearing, that RBH's treatment had left them feeling 'absolutely worthless', and that they had 'no doubt at all that we were treated this way because we are not from the country'.
READ MORE: A forgotten child in the Greater Manchester flats that are full of fear
The inquest heard evidence from witnesses involved in the case - from repair staff who inspected his home, to the medics who looked after him. And it revealed a chain of poor decisions - a litany of ways in which Awaab and his family were failed. They began before he was born, and went right up to the hours before his death.
Bad advice
The first failure came more than a year before Awaab had even been born. When Mr Abdullah first began to notice 'black dots on the surface' in his kitchen in autumn 2017, it was the first time he had ever come across the issue of mould.
Awaab's law - sign the petition
Awaab Ishak died aged two after living in a damp and poorly ventilated flat led to him suffering heart and lung failure.
His home was described by experts as 'unfit for human habitation' but the housing association who owned it did not act to sort out the problems despite his parents' desperate pleas.
It was a tragedy that could and should have been prevented. That's why the Manchester Evening News and Shelter are campaigning for a change in the law that would compel housing associations not to allow any other child, or anyone else, to suffer in damp and mouldy social housing.
The Social Housing Regulation Bill is currently going through Parliament, and if approved it would bring back regulation on consumer standards for social housing. The M.E.N. calls on all MPs and peers to support Bill and strengthen it, by including Ofsted-style inspections at short notice and increased professionalisation of housing management to improve the experience of tenants, including those living with damp and mould.
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He took a photo of it on his phone and showed it to reception at an office for Rochdale Boroughwide Housing (RBH), the social landlord which owns and manages properties on the Freehold estate. The inquest heard that a man working in the office told Mr Abdullah he 'would have to paint over it' - but he never said to use specialist anti-mould paint, or gave any other advice.
Mr Abdullah followed the advice, and repeated it a year later when the mould returned, covering a larger area of his flat than in 2017. By this time, his wife Ms Amin was pregnant with Awaab, who would be born at Royal Oldham Hospital on December 13, 2018.
Asked about the effectiveness of painting over mould, mycology expert Prof Malcolm Richardson told the court: "You will not stop the mould reappearing over a period of time if the damp situation is not fixed." Nadhia Khan, RBH's director of customer and community, told the inquest that tenants would now not be told to resolve mould issues themselves - with contractors carrying out the work instead.
Landlord should've taken responsibility
Less than three days into Awaab's inquest, RBH made the bombshell admission that the approach it took to dealing with complaints about the family's home had been 'inappropriate', and that it 'should have taken responsibility for the mould issues'. Mr Abdullah made several complaints about mould at his home, along with repeated attempts to move home, during the course of Awaab's life.
Damp and mould was already a major issue for hundreds of RBH tenants. The housing association had 600 outstanding mould treatments to carry out when Mark Wrigley took over as disrepair manager in 2019, and he admitted that, for the painting team he oversaw, 'eventually, the mould took over the painting.'
Mr Abdullah responded to a Facebook post about damp and mould, which led to a disrepair claim being filed against RBH by Anthony Hodari solicitors in June 2020. As part of the process, Mr Wrigley inspected the family's home on July 14, and he believed the problem was being caused by a 'lifestyle' issue, with other workers at RBH making similar comments in a later visit.
Cooking and bathing were believed to be adding to moisture in the property by RBH - including claims that 'ritual bathing' involving a 'bucket' was taking place, although the court heard workers never asked the family about this directly, while Mr Abdullah insisted it did not take place. But surveys carried out before and after Awaab's death found the property had insufficient ventilation, and coroner Joanne Kearsley insisted cooking and showering would take place in 'anybody's home'.
Daniel McVey, building surveyor at Rochdale Council who inspected the property after Awaab's death, found it to be 'unfit for human habitation' without repairs carried out. Housing ombudsman Richard Blakeway told the court it can be 'too simplistic' for housing associations to blame tenants for damp and mould.
He said: "There may be factors like fuel poverty, age and design of homes, which may make the risk of damp and mould greater... those are known risks and therefore it's important for them to think about their approach to make sure they address those known challenges." Ms Khan said RBH eventually fitted new ventilation in the bathroom and kitchen of the property following Awaab's death, along with a number of other properties on Freehold.
IT mix-up
Awaab's inquest has heard how RBH staff used a number of different IT systems, but there is one programme called CRM which they should all be using. Yet this wasn't always the case when issues were raised by Awaab's family, or when issues were raised on their behalf by health and social care professionals.
It meant that vital pieces of information were not always available to RBH staff who were dealing with the family - with several workers even claiming they were unaware Awaab lived at the flat. After seeing the family at their home, health visitor Caroline Ridley sent a letter to RBH about the damp and mould.
In the letter, she referred to Mr Abdullah and Ms Amin by name, as well as their 'young child Awaab'. The letter was filed to an IT system other than CRM at RBH by Lorna O'Malley, who was an apprentice in the Homechoice team at the time, the inquest heard.
A number of workers who dealt with complaints and contacts from Mr Abdullah gave accounts of where they filed and checked information about the family - with some using CRM, and others using different systems. Disrepair manager Mark Wrigley was made aware of Ms Ridley's letter the day before his inspection, but told court he did not see it.
He believed Mr Abdullah was living alone in the property at the time of the inspection. Mr Wrigley was one of a number of workers at RBH who said they would have acted differently if they knew a young child was living at the property.
Managers at RBH told the court that more information is now being collected from tenants who report damp and mould issues, so workers will be aware of children at the property. Meanwhile, all staff are being trained to use CRM, head of customer experience Phil Heron explained.
Breakdown in communication
Both RBH and Anthony Hodari solicitors drew up their own policies regarding disrepair claims in good faith. But when the two policies clashed with each other, it led to a vacuum in communication which would have devastating consequences.
In 2020, RBH had a policy not to carry out remedial works on properties which were subject to legal claims, until they had secured agreement to the works from the tenant's solicitor. It meant that Mr Wrigley visited Awaab's home on July 14, 2020, to draw up a list of repairs that needed carrying out, but the work could not take place until the green light had been given by Anthony Hodari.
Mr Wrigley told the inquest that mould treatment and plastering work needed to be carried out at the property. Andrew Foster, a technical inspector at RBH who visited the property in November 2020 following reports of a leak in the flat below, also found the extraction fan in the bathroom was 'not working properly' and felt new ventilation units could be installed.
The housing association never carried that work out because it believed the property was still subject to a legal claim even after Awaab's death - but Stephen Lund, director at Anthony Hodari, told the inquest the firm had in fact dropped the case in September 2020, weeks before Awaab died. Mr Lund explained the firm has its own policy not to inform housing associations when cases are dropped to avoid prejudicing other legal action involving the tenant.
Meanwhile, early years worker Lauren Hughes had also been in touch with RBH about the damp and mould in November and December 2020, but ultimately had no response. In a series of admissions made by RBH last week, it accepted that it should have carried out the works as there was no legal requirement to wait for the go-ahead from solicitors.
It's not the only lack of communication that was cause for concern either. The coroner also raised concerns about information not being passed on between medical professionals and the family's GP.
Unclear hospital advice
The final failure affecting Awaab's life would ultimately prove to have the gravest consequences. The toddler was admitted to Rochdale Urgent Care Centre with breathing difficulties on December 19, 2020.
He was transferred to Royal Oldham Hospital for further observation, where he was treated for croup by Dr Phillipa Marshall. With lockdown restrictions in place at the time, only one parent was allowed to be with Awaab at the hospital, and his mum stayed with him.
Dr Marshall told the court she used Google Translate to communicate with Ms Amin, whose English was more limited than Mr Abdullah's. As she discharged the toddler, Dr Marshall advised that Awaab should 'go to hospital' if he struggled with his breathing again, but she did not specify Royal Oldham Hospital.
Awaab's family contacted community nurses on the morning of December 21 as Awaab's breathing deteriorated, before Mr Abdullah took his son to Rochdale Urgent Care Centre on December 21. Awaab was transferred to Royal Oldham Hospital and suffered a cardiac arrest as a result of respiratory failure.
Northern Care Alliance, the NHS trust which runs both sites, admits that Awaab 'would not have died at the time he did on the balance of probabilities' if he had been admitted to Royal Oldham Hospital sooner that day. Dr Sri Nagesh Panasa, who carried out a review into the case, said Awaab would have benefitted from being seen by additional staff with specialist expertise at Oldham.
He told the inquest that a 'language line' translation service is available for NHS staff at Northern Care Alliance and it is 'good practice' to ask families to repeat the advice they are given, to make sure they know everything they need to. He added that community nurses are now told to advise families to call 999 in the circumstances Mr Abdullah had been in on the morning of December 21, 2020.
READ MORE ON THIS STORY:
- 'We complained so many times about mould in our home but they did nothing to help us
Coroner rules Awaab Ishak, 2, died after mould wasn't treated at his home
Awaab Ishak's death shames the country - this is what needs to change now
All the ways tragic two-year-old toddler Awaab Ishak was failed before his death
Actions leading to Awaab Ishak's death were 'unacceptable', Downing Street says
