An official coroner’s report obtained by The Tribune says British mortuary workers were exposed to a “significant chemical hazard” after opening coffins containing victims of the Air India Boeing 787 crash in Ahmedabad. Senior Coroner Professor Fiona J. Wilcox found “dangerously high” concentrations of formalin, and detected carbon monoxide and cyanide at Westminster Public Mortuary after bodies repatriated from India were unwrapped.
Wilcox’s report states the remains had been “wrapped and saturated in high concentrations of formalin (apparently 40%)” and that this presented a clear chemical risk to mortuary users. The document explains that formalin contains formaldehyde, which is volatile, can cause severe respiratory irritation, is carcinogenic and has been linked to acute myeloid leukaemia. The report cites expert advice that exposure can lead to metabolic acidosis, bronchospasm, pulmonary oedema and death. Wilcox adds that formalin can break down with heat and light to release carbon monoxide, and when combined with ammonia from decomposition can produce cyanide — both highly toxic.
Testing after coffins were opened found formalin at dangerously high levels and measurable, dangerous concentrations of carbon monoxide and cyanide. Wilcox says many mortuary staff were unaware of the hazard and that environmental monitoring is “apparently not usual” in public or hospital mortuaries. She warns of an “under appreciation across mortuaries of the dangers posed by formalin,” noting mortuaries frequently receive bodies preserved in formalin and that, without monitoring and suitable protective equipment, staff face serious risks “including of death.”
Wilcox has issued a Regulation 28 report — a notice to prevent future deaths — to the Secretaries of State for Housing, Communities and Local Government and for Health and Social Care; those departments are required to respond within 56 days. The report is dated September 10, 2025, but was published only recently after the normal delay while Regulation 28 notices were sent to government departments and interested parties.
The chemical-exposure findings follow earlier concerns about the handling and identification of some repatriated remains. Aviation lawyer James Healy‑Pratt, representing more than 20 British families, told the PA news agency that routine checks uncovered errors: one casket contained “co-mingled” remains and another family was informed a coffin “contained the body of someone else entirely.” Healy‑Pratt said those problems were identified because Wilcox “picked up DNA anomalies” during the repatriation process. A family of three British victims buried in India said the experience revealed a “clear lack of transparency and accountability” and showed failures in coordination and care between British and Indian authorities.
The crash on June 12 killed 241 people on board, including 52 British nationals, and at least 19 people on the ground. Many bodies were flown to London for examination and release to families. Wilcox’s findings indicate that handling some remains posed unanticipated dangers that required police chemical specialists and the Environment Agency.
Separately, the report and press coverage note renewed scrutiny of Air India’s safety culture after India’s Directorate General of Civil Aviation (DGCA) found an Airbus A320 operated on commercial flights without a valid airworthiness certificate — reportedly flying eight flights after the certificate expired. Air India described the lapse as “regrettable,” said it reported the issue and suspended personnel involved. Past DGCA audits have highlighted training gaps and simulator approval issues; Reuters reported the regulator identified 51 safety lapses across Air India’s operations in July. In response to scrutiny after the June crash, Air India said it was conducting one-time safety checks on its Boeing 787 fleet, which delayed some long-haul services.
Wilcox’s chemical-hazard warnings, the earlier misidentification issues and ongoing regulatory action in India point to failures during the crash aftermath and in airline oversight. For victims’ families, the emerging picture suggests basic safeguards — identification, mortuary safety and airworthiness checks — were not consistently maintained at critical moments. Air India has been approached for comment.
