A coroner has said the death of an “engaging, lively, endearing” two-year-old from prolonged exposure to mould in his family’s flat should be a “defining moment” for the UK’s housing sector. Awaab Ishak died in 2020, eight days after his second birthday, as a direct result of black mould in the flat he lived in. About 450,000 homes in England have problems with condensation and mould and the verdict triggered calls from paediatric doctors for better reporting of air quality problems in homes. And England’s housing ombudsman, Richard Blakeway, said landlords must make plans to tackle the “real risk of worsening damp and mould issues” as energy bills soar. Michael Gove, the levelling up, housing and communities secretary, said the death was “an unacceptable tragedy” and that “it beggars belief” that the chief executive of the social housing provider was still in office. But he also said the government had been too slow to toughen regulation of social housing. “It’s five years since the Grenfell tragedy, we should have been legislating earlier,” he said. He also admitted to fears about living conditions for renters during the cost of living crisis. Greg Fell, the vice-president of the Association of Directors of Public Health, said the verdict “tragically underscored” the “hidden risk” to public health posed by mould. “It’s a significant threat,” he said. “We are going into a winter where people will be turning the heating down in a way that encourages more damp in our homes.” After a narrative conclusion was recorded at Rochdale coroner’s court, lawyers for Awaab’s parents read a statement in which they accused the social housing provider, Rochdale Boroughwide Housing (RBH), of doing nothing over a number of years to treat the mould problem that killed their son. “We cannot tell you how many health professionals we have cried in front of and Rochdale borough housing staff we have pleaded to expressing concern … We shouted out as loudly as we could,” they said. They accused RBH of not caring and said they had no doubt they were treated that way “because we are not from this country and less aware of how the systems in the UK work. “Rochdale Boroughwide Housing, we have a message for you: stop discriminating. Stop being racist. Stop providing unfair treatment to people coming from abroad who are refugees or asylum seekers. Stop housing people in homes you know are unfit for human habitation. We were left feeling absolutely worthless at the hands of RBH.” The mould that killed Awaab was in the bathroom and kitchen of the flat in Rochdale he shared with his parents, Faisal Abdullah and Aisha Amin. Abdullah first reported the mould to RBH in 2017. A number of things went wrong, some of them contributing to his death, the senior coroner Joanne Kearsley said. “Awaab Ishak died as a result of a severe respiratory condition caused due to prolonged exposure to mould in his home environment,” she said. “Action to treat and prevent the mould was not taken. His respiratory condition led to respiratory arrest,” she said. “I’m sure I’m not alone in having thought: how does this happen? How, in the UK in 2020, does a two-year-old child die from exposure to mould in his home? “The tragic death of Awaab will, and should, be a defining moment for the housing sector in terms of increasing knowledge, increasing awareness and a deepening of understanding surrounding the issue of damp and mould.” Addressing the family, Kearsley said: “I hope you know that Awaab will, I am sure, make a difference for other people.” Senior doctors called on the UK government to set up a reporting channel for renters to raise the alarm about indoor air quality problems and to help with necessary improvements. “Increasing evidence suggests a rising number of families are living in poor-quality accommodation, with detrimental impacts on children’s health,” said Dr Camilla Kingdon, the president of the Royal College of Paediatrics and Child Health. “Cold and damp housing conditions can lead to increased risk of asthma, respiratory infections, slower cognitive development, and higher risk of disability, mental health problems in children.” Abdullah arrived in the UK from Sudan in 2016 and was joined by his wife in 2017. He had some understanding of and ability to converse in English. His wife had very little English. After reporting the mould in 2017, Abdullah was told to paint over it, which he did several times. Kearsley said she was satisfied that Abdullah “would not have fully understood to treat the mould with anti-mould treatment/paint”. In 2020, Abdullah instructed solicitors via a claims company. It was RBH policy – and that of other providers in the industry – not to tackle disrepairs until there was an agreement from the claimant’s solicitors. RBH accepted at the inquest that a more proactive approach should have been taken to tackle the mould. A health visitor also wrote, twice, to RBH in 2020, expressing concern about the mould and the negative health effects it could have. Kearsley said the mould was due to “normal daily living activities” and a lack of effective ventilation. “I find as a matter of fact that no action was taken and, from July 2020 until December 2020, Awaab continued to have chronic exposure to harmful mould.” The coroner expressed concern about an “evident gap” in information sharing between health visitors, midwives, early help services and the GP. Awaab was treated at Royal Oldham hospital on 19 December and discharged. Kearlsey said the family should have been told to call an ambulance or take him directly to Royal Oldham hospital if he had further difficulties. He died on 21 December. Kearsley said mould in properties was not particular to Rochdale, or to social housing. She supported a call for the government’s decent homes standard to be strengthened to include damp and mould, and said she would be writing a report for the prevention of future deaths and sending it to government ministers. Awaab’s parents said their son was a beautiful boy. “He was always full of smiles. He liked a joke and was full of life. He used to enjoy playing on his bike. He always wanted to be with us. His absence leaves a huge void.” They said they hoped RBH would deal with a similar issue to theirs in a more “humane, efficient and professional” way. Gareth Swarbrick, the chief executive of RBH, said in a statement he was “truly devastated about Awaab’s death and the things we got wrong”. Nothing could bring Awaab back, he said, but added: “We have and will continue to learn hard lessons from this. “We didn’t recognise the level of risk to a little boy’s health from the mould in the family’s home. We allowed a legal disrepair process, widely used in the housing sector, to get in the way of promptly tackling the mould. We must make sure this can never happen again. Awaab’s death needs to be a wake-up call for everyone in housing, social care and health. “We will take responsibility for sharing what we have learned about the impact to health of damp, condensation and mould with the social housing sector and beyond. “The coroner recognised the changes we have made to our procedures, IT, communications and training. We note the coroner’s words that she was impressed with the learning RBH has taken and desire to share with others.”