British mortuary workers were exposed to what Senior Coroner Professor Fiona J Wilcox describes as a “significant chemical hazard” when they opened coffins containing victims of the Air India Boeing 787 crash in Ahmedabad, according to an official report obtained by The Tribune.
Wilcox’s document warns of “dangerously high” levels of formalin, carbon monoxide and cyanide detected at Westminster Public Mortuary after bodies repatriated from India were unwrapped. The coroner records that the remains had been “wrapped and saturated in high concentrations of formalin (apparently 40%)”. She says: “It was apparent that there was a significant chemical hazard from the formalin to all users of the mortuary.”
The aircraft crashed on June 12 shortly after take-off from Ahmedabad, killing 241 people on board, including 52 British nationals, and at least 19 on the ground. Many of the bodies were brought to London for examination and release to families. Wilcox’s findings show that handling some remains posed unanticipated risks for mortuary staff and required involvement from police chemical specialists and the Environment Agency.
The report explains how formalin becomes hazardous in confined spaces. Formalin contains formaldehyde, which “can cause severe respiratory irritation”, is volatile so it disperses into the atmosphere, and is “carcinogenic and known to cause acute myeloid leukaemia”. Expert advice cited in the report states formalin’s toxic effects can include “metabolic acidosis, bronchospasm, pulmonary oedema and death”. Wilcox notes that “with heat and light exposure, it breaks down releasing carbon monoxide, which is highly toxic”, and that when mixed with ammonia from decomposition, “cyanide, which is also highly toxic, can be released”.
The dangers were material: “Levels of formalin were found to be dangerously high, and carbon monoxide and cyanide were also detected in the mortuary at dangerous levels following opening of the coffins and unwrapping of the bodies,” Wilcox writes. She highlights a lack of preparedness in UK mortuaries, saying many workers “were unaware and were surprised by the nature of the danger from the formalin”, and that “it is apparently not usual for environmental monitoring to be routinely available in either public or hospital mortuaries”.
Wilcox identifies an “under appreciation across mortuaries of the dangers posed by formalin”, notes that mortuaries “frequently receive bodies preserved in formalin”, and warns that without monitoring and appropriate protective equipment, staff face risks “including of death”. She concludes that “action should be taken to prevent future deaths” and has issued a Regulation 28 report notifying the Secretaries of State for Housing, Communities and Local Government and for Health and Social Care; they must respond within 56 days.
Although the report is dated September 10, 2025, it appears to have been circulated publicly only recently, following the typical delay while Regulation 28 notices are issued to government departments and interested parties before publication.
The chemical-exposure findings follow earlier concerns about handling and identification of some repatriated remains. Aviation lawyer James Healy-Pratt of Keystone Law, representing more than 20 British families, told the PA news agency that routine checks uncovered significant errors: one casket contained “co-mingled” remains and another family was told a coffin “contained the body of someone else entirely”. He said those problems were identified due to Wilcox’s early work, noting she “picked up DNA anomalies” in the repatriation process.
A family of three British victims buried in India said the experience showed a “clear lack of transparency and accountability” and reflected a wider failure between British and Indian authorities to act with care, coordination and respect.
Separately, Air India is facing renewed scrutiny of its safety culture after India’s Directorate General of Civil Aviation (DGCA) discovered an Airbus A320 flew commercial services without a valid airworthiness certificate. Reports said the aircraft operated “eight flights” after the certificate expired. Air India called the lapse “regrettable”, said it had reported the issue and suspended personnel involved, according to Channel NewsAsia.
Past DGCA audits have flagged issues including training gaps and simulator approvals. Reuters reported in July that the regulator identified 51 safety lapses across Air India’s operations. In response to heightened scrutiny after the June crash, Air India said it was conducting “one-time safety checks” on its Boeing 787 fleet, causing delays to some long-haul services.
Wilcox’s chemical-hazard warnings, earlier misidentification of remains and ongoing regulatory action in India together point to failures spanning the crash aftermath and airline oversight. For victims’ families, the emerging picture suggests basic safeguards—identification, mortuary safety and airworthiness checks—were not maintained at critical moments. Air India has been approached for comment.
