Unnamed deceased persons · Prevention of Future Deaths report

On 12th June 2025 at 13:39 hours, an Air India Boeing 787 took off from Ahmedabad Airport, India to fly to London Gatwick. It crashed 32 seconds after take-off, falling from an altitude of 600 feet. 241 people died who were on the aircraft, and at least 19 people who were on the ground. There was one surviving passenger.

No inquests have yet been heard. This report is based upon my duty under Regulation 28 being engaged in respect of the hazard presented to all mortuary users from the method in which bodies of deceased persons being repatriated to the UK were preserved and returned.

Following the incident a number of deceased persons were repatriated to Westminster Public Mortuary. The remains of these deceased persons were wrapped and saturated in high concentrations of formalin (apparently 40%) as a preservative and returned in lined coffins. On opening the coffins, it was apparent that there was a significant chemical hazard from the formalin to all users of the mortuary.

Expert evidence was sought from Police CBRN, the EPA, the pathologist etc and appropriate systems were put in place to mitigate the risk including the use of environmental monitoring, breathing apparatus and other appropriate equipment.

It became apparent that many of the mortuary users appeared unaware and were surprised by the nature of the danger from the formalin, which is commonly used to preserve human remains and especially when bodies of deceased persons are repatriated from abroad. It is apparently not usual for environmental monitoring to be routinely available in either public or hospital mortuaries.

Expert advice summarised the danger of formalin to be that formalin contains formaldehyde.
This substance can cause severe respiratory irritation.
It is a volatile substance which means that it disperses into the atmosphere.
It is carcinogenic and is known to cause acute myeloid leukaemia.
It has toxic effects including metabolic acidosis, bronchospasm, pulmonary oedema and death.
With heat and light exposure it breaks down releasing carbon monoxide which is highly toxic.
If it mixes with a source of ammonia (commonly seen with decomposition), cyanide which is also highly toxic can be released.

Levels of formalin were found to be dangerously high, and carbon monoxide and cyanide were also detected in the mortuary at dangerous levels following open of the coffins and unwrapping of the bodies of the deceased persons who had been repatriated.

1. There is an under appreciation across mortuaries of the dangers posed by formalin to the health of all mortuary users.

2. That mortuaries frequently receive bodies preserved in formalin.

3. That formalin is not routinely monitored in mortuaries.

4. That as such appropriate equipment may not be available nor used when mortuaries handle bodies significantly contaminated with formalin, thus exposing users of mortuaries to health risks including risk of death as outlined above in box 4.