The coroner Philip Barlow's report was published on 20/04/2021 and contains the coroners concerns and recommendations for actions. It had already been established in December 2020 that one of three medical causes of the death was air pollution. 

Among the matters of concern are: 

The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.

There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.

The government has been under pressure to bring down emissions quickly due to international and European obligations, as well as national legislation. This was highlighted in February 2018 when campaigners won a third high court victory over ineffectiveness in government policy, with Mr Justice Garnham saying:

The Environment Secretary must ensure that, in each of the 45 areas, steps are taken to achieve compliance as soon as possible, by the quickest route possible and by a means that makes that outcome likely.

 Poor air quality has a significant effect on health as these figures show:

• In the UK alone, long term exposure to man-made air pollution has an annual effect equivalent to between 28,000 and 40,000 premature deaths (the number of people killed in road fatalities was 1,792 people in 2017).
• According to the World Health Organisation the estimated annual death toll is 7 million people globally.
• The Royal College of Physicians and the Royal College of Paediatrics and Child Health estimate the cost of air pollution to the UK to be more than £20bn a year.
• Stated in the government’s walking and cycling vision, ‘Gear Change’, meeting the targets to double cycling and increase walking would lead to savings of £567 million annually from air quality alone, prevent 8,300 premature deaths each year and provide opportunities to improve green spaces and biodiversity.

The coroners report can be found here.