A two-year-old boy died due to black mould in his home that was "unfit for human habitation", an inquest has found.
Awaab Ishak would enjoy playing outside, freed from the conditions at home that blighted his health, and had celebrated his second birthday just a week before he died from a respiratory condition in December 2020.
He lived in a one-bedroom flat with his parents Aisha Aminin and Faisal Abdullah, who had previously complained to Rochdale Boroughwide Housing (RBH) about the mould, an inquest was told.
Following six days of evidence at Rochdale Coroners' Court, it was concluded that he "died as a result of a severe respiratory condition caused due to prolonged exposure to mould in his home environment."
The youngster's family said after the hearing: "We cannot tell you how many health professionals we've cried in front of and Rochdale Boroughwide Housing staff we have pleaded to, expressing concern for the conditions ourselves and Awaab have been living in.
"We shouted out as loudly as we could, but despite making all of those efforts, every night we would be coming back to the same problem."
Coroner Joanne Kearsley said the toddler's death should be a "defining moment" for the housing sector and No.10 blasted the circumstances in which the youngster died as 'unacceptable'.
Ms Kearsley told the court: "I'm sure I am not alone in asking how does this happen? How in the UK does a two-year-old child die from exposure to mould in his home?
"The evidence from this inquest quite clearly showed that this issue is not simply a Rochdale problem. Nor is damp and mould simply a social housing problem."
Ms Kearsley did not find the actions of RBH or Northern Care Alliance, an NHS trust, were gross failures that could amount to "neglect", reports Manchester Evening News.
Addressing the toddler's parents, Ms Kearsley said: "I hope you know that Awaab will, I am sure, make a difference for other people."
The family said they were left feeling "absolutely worthless" by RBH and alleged they were treated that way because they are not from the UK.
Chief executive of RBH, Gareth Swarbrick, said Awaab's death should be a "wake-up call for everyone in housing, social care and health".
He said: "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."
In light of the tragedy the government said it would 'no longer stand for' landlords failing their tenants. A No10 spokeswoman said: "Clearly, this is a tragic case and Prime Minister's thoughts are with his family at this extremely difficult time.
"Clearly the circumstances in which he died are unacceptable, and we will no longer stand for unresponsive landlords failing in their responsibilities to tenants."
She added: "More broadly, we also continue to deliver on our housing reforms. That will include forcing developers to pay to fix unsafe buildings, better protect the rights of tenants and the private rented sector, [and] ensure that social landlords do not put people's lives and livelihoods at risk."
Ms Kearsley said she had taken into account testimony from housing ombudsman Richard Blakeway, who found an "over-reliance being placed on the contribution of a tenant's lifestyle as the cause" of damp and mould.
She told the court: "Having considered all the evidence in this case I find that the most likely cause of any damp or moisture in 2020 was, more likely than not, due to normal daily living activities albeit there may have previously been other issues such as leaks from other properties.
"To be clear there is no evidence that the ways of living by the family were in any way excessive.
"Furthermore I find as a matter of fact that the ventilation in the bathroom was not effective, there was a lack of ventilation in the kitchen and an overall lack of an effective ventilation system in the property.
"This was a direct contributing factor in the development of the mould."
In her findings, the coroner described Awaab as "an engaging, lively, endearing two-year-old".
She said Mr Abdullah reported mould developing in the Tweedale Street flat to RBH in 2017 and was told to paint over it.
In June 2020, Mr Abdullah instructed solicitors and initiated a claim over the recurring issue but policy meant any repairs would not be done until an agreement had been reached, the inquest heard.
A health visitor also contacted RBH to raise the issue in July 2020 and an inspection that month found mould in the kitchen, bathroom and a bedroom cupboard needed treatment.
Ms Kearsley said the mould was due to "normal daily living activities" and a lack of effective ventilation.
She said: "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."
Awaab was taken to Rochdale Urgent Care Centre on December 19 with shortness of breath and transferred to Royal Oldham Hospital before being discharged, the court heard.
The coroner said the family should have been told to call an ambulance or take him directly to Royal Oldham Hospital if he had further difficulties.
Awaab deteriorated the next day and his parents were advised by the Community Children's Nursing Team to take him back to the Rochdale Urgent Care Centre.
He went into respiratory arrest and then cardiac arrest while being transferred to Oldham, the inquest heard.
He died after arriving at Oldham.
Ms Kearsley gave a narrative conclusion for Awaab's death, with a medical cause of acute airway oedema with severe granulomatous tracheobronchitis, due to environmental mould exposure.
She said: "Awaab Ishak died as a result of a severe respiratory condition caused due to prolonged exposure to mould in his home environment.
"Action to treat and prevent the mould was not taken. His severe respiratory condition led to Awaab going into respiratory arrest.
"The medical advice given to his parents led to Awaab receiving sub-optimal ventilation of his airway which was unable to prevent his cardiac arrest."
Ms Kearsley said the issue is "not simply a Rochdale problem".
She said she will be writing a report for the prevention of future deaths and will write to the minister for Housing, and Health Secretary Steve Barclay, to raise issues.
Awaab and his family are far from the only families living on the Freehold estate to be affected by severe damp and mould. Others have tried and failed to move home, with some even having letters from their GPs urging them to leave.
Housing Secretary Michael Gove has said it "beggars belief" that the chief executive of Rochdale Boroughwide Housing is still in his job following the death of the two-year-old.
In a pooled clip for broadcasters, Mr Gove said he has summoned the head of the housing association concerned to the Department for Levelling Up, Housing and Communities.
"This is an unacceptable tragedy," he said and added that local authorities and housing associations have a "basic responsibility" to ensure people have "decent homes".
In a pooled clip for broadcasters, Mr Gove said they could not blame a lack of government funding for the death of two-year-old Awaab Ishak.
"We all know that local authorities are facing challenging times when it comes to finance but, frankly, that is no excuse," he said.
"When you have got a situation where you have a young child in a house that is unfit for human habitation, it is a basic responsibility of the local authority - but particularly the housing association - to make sure that people are in decent homes.
"All this what-aboutery, all this 'Oh, if only we had more government money' - do your job, man."
Addressing Awaab's family as she gave her conclusion, Ms Kearsley said: "I hope we have been able to provide you with some of the answers to the questions that you had about your son's death.
"But I do appreciate that nothing I say or do can bring Awaab back. More than anything, I hope you know that Awaab will - I am sure - make a difference for other people."
