Awaab Ishak: Pattern of exclusion and marginalisation in housing association where toddler died

Video report by Granada Reports journalist Zoë Muldoon

The family of a toddler who died from exposure to mould were subject to "lazy assumptions" by a housing association which had a "wholly unacceptable" attitude towards asylum seekers and refugees, a report has found.

Awaab Ishak died following prolonged exposure to mould at his home in Rochdale in 2020, just over a week from his second birthday.

A report by the Housing Ombudsman was ordered after his inquest which found his parents had raised multiple concerns about damp and mould with Rochdale Boroughwide Housing (RBH).

The report said a pattern of exclusion and marginalisation was present when the toddler died, with the family's treatment "based on assumptions as to who they were and how they lived."

One former staff member even said their boss said many who complained about mould and living conditions were "refugees" who were "lucky to have a roof over head".

"Combined together," the Ombudsman continues, "It paints a disturbing picture of residents being judged entirely by staff members’ held prejudices, lazy assumptions and an attitude towards asylum seekers and refugees that is wholly unacceptable."

The report said a culture of 'othering' was deep-rooted in RBH's problems, consisting of what the watchdog called "a pattern of exclusion and marginalisation based on identities perceived as different".

It also found a tenant's lifestyle was "often used as a reason to dismiss their concerns and apportion blame without any real focus on the limitations residents faced with modern day living".

It concluded that the root cause of service failure within Rochdale Boroughwide Housing was a propensity to dismiss residents and their concerns out of hand, with staff believing that they knew better and that the expectations of their residents were unreasonable.

Overall the report, which suggests 20 recommendations for improvements, looks at initial lessons identified by the landlord following the toddler's death.

It also calls for better engagement with residents, assessment of families needs and improved record keeping of complaints.

The report found that "the dismissive and discriminatory attitude towards residents revealed at Awaab Ishak’s inquest was not restricted to his family’s experience", and listed multiple other cases.

The Ombudsman reviewed complaints from 2019 up until the beginning of 2023 and made 15 findings in several cases investigated since the inquest.

It found maladministration for 10 of the complaints – a maladministration rate of 67%, including three findings of severe maladministration.

For example, one resident reported concern after her young son developed chest problems which she believes is due to severe damp and mould in her home.

RBH described the report’s findings as “sobering but not unexpected” and said there had been “significant learning from the tragic death of Awaab Ishak”.

In a statement, it said it “recognised that too often damp and mould was not seen as a serious issue and was attributed to a resident’s lifestyle”.

On the treatment of residents, RBH vowed to “put this right” and said it had already “begun a culture shift programme across the organisation”.

Richard Blakeway, Housing Ombudsman, said: “Our investigation has highlighted that culture change will be central to the landlord’s recovery.

“The weakness in policies, repeated failures and failure to learn from complaints has led us to conclude there was wider service failure by the landlord in areas other than its response to damp and mould, including record keeping and communication.

“Our investigation found reoccurring instances of residents being treated in dismissive, inappropriate or unsympathetic ways. In some instances, the language used was derogatory.

“It is highly unlikely that this endemic behaviour of ‘othering’ is isolated to a single landlord and the social housing sector should consider whether they also need to turn over the stone and do a deep dive into their culture and whether they are living their social purpose.

“It is encouraging to see that the new leadership at the landlord is determined to lead from the front with the development of their recovery plan.”

A string of recommendations, along with seven key themes, were identified by the Ombudsman:

Finding its silence

The theme "finding its silence" expressed how the landlord did not "go far enough" to uncover where residents were not reporting damp and mould issues.

The Ombudsman added: "This included flawed reviews that did not uncover the damp and mould that was present on various estates."

"This further highlights the risk for other landlords of relying on one method and one-off exercises to identify the extent of problems."

The landlord has since written personalised letters to residents encouraging reporting of damp and mould, provided updates on planned property works and resident engagement events. It has also started a stock condition survey.

The Ombudsman also said "action should also be taken when reletting homes and consideration taken of when residents should be moved to another property".

Treat residents fairly

During the investigation, the Ombudsman looked at the responses the landlord gave to its call for evidence as part of the Spotlight report shortly after the death of Awaab Ishak.

The Ombudsman said: "Much of the language used was tenant blaming, using lifestyle and cultural barriers as key reasons for the issues."

The investigations also found that the "dismissive and discriminatory attitude" towards residents was not limited to Awaab Ishak’s family, nor were the complaints about damp and mould.

Other issues arose in cases involving "general repairs, the ending of tenancies and anti-social behaviour".

It continued: "This strongly indicates that unsympathetic, inappropriate, or even heavy-handed behaviour towards residents is present throughout the landlord’s interactions.

"While all staff were provided with ‘Respect’ training at induction there is no evidence this is repeated.

"This is a significant concern and requires a comprehensive and sustained focus on shifting behaviour and culture."

Proactive communication strategy

The Ombudsman found that communications by the landlord about damp and mould were "at times scant".

They added that the landlord's website information does not cover how the landlord will tackle the problem and instead addressing what the resident should do.

The landlord intends to produce more information for residents, including a video, that will be left with a resident following mould treatment and in the tenancy sign-up pack, actions we have welcomed.

The Ombudsman recommends the landlord further engage residents from across its diverse population in the co-design of new information to ensure it is accessible, impactful and effective.

Record keeping

The ombudsman described record keeping as a "key theme" running through Rochdale Boroughwide Housing’s complaints, with missing repairs records, different systems holding different information, repairs information logged against the wrong address and key details being stored on individual staff computers.

The Ombudsman also found that the landlord lost most of its email data in 2020 and there was evidence of a lack of synchronisation between multiple databases.

The landlord is now taking steps to encourage a culture shift to updating live documents in the databases, including reviewing the permissions to ensure document integrity, and the Ombudsman proposes the landlord prioritises a tenancy audit to establish who is living in the homes, vulnerabilities and the presence of children.

Damp and mould strategy and net zero plans

The landlord aims to have a dedicated damp and mould strategy in place by April 2023 and is deploying technology to monitor humidity in their homes.

The landlord has introduced a priority system for assessing how long a mould repair could take but the Ombudsman feels it did not sufficiently recognise the severity of the mould or whether the location is critical, only how relatively widespread it is.

While the landlord created a damp and mould task force in 2022, the Ombudsman has concerns about its training, which seems to concentrate on the technical requirements on a landlord and whether it needs to concede liability when a disrepair claim has been submitted.

Empower staff

The landlord’s staff "did not have the sufficient training" to explore reports of damp and mould or make the correct decision on how to handle damp and mould reports.

Staff did not possess the "empowerment to challenge appropriately if they felt the response inadequate".

The Ombusdman said: "The landlord intends to set up training programmes around diagnostic and problem-solving skills."

It continued: "It is also clear some staff did not feel comfortable raising their issues through the whistleblowing process in place within the landlord, opting instead to talk directly to the Housing Ombudsman."

The landlord intends to "communicate its whistleblowing policy consistently and to encourage a culture of ‘calling out’ and is also providing specific Equality and Diversity training that includes confidence building to empower staff to challenge when they feel policies or procedures and a process-driven culture has overtaken doing what is right.

Organisational learning

The Ombudsman continued: "Until the inquest, the landlord did not show a strong ability to learn from its mistakes or take opportunities to improve from them.

"There were several issues with the landlord’s complaints policy from 2022, which did not include an emphasis around equality – which is particularly concerning as many of the issues the Ombudsman identified in its investigation concern the fair treatment of residents, particularly those with protected characteristics."

The Ombudsman has suggested the landlord update its complaints policy and self-assess it against the Code.