A new report into the death of a five-year-old boy who died days after being sent home from a hospital emergency department has found the NHS failed to listen to a “mother’s instinct”.
Background to the case
Yusuf Nazir, a five-year-old with asthma and recurring chest infections, first became unwell on 15 November 2022. His mother, Soniya Ahmed, took him to a GP, where he was prescribed antibiotics for a sore throat.
Concerned by his condition deteriorating, his parents brought him to Rotherham General Hospital that evening, where they waited six hours before Yusuf was seen and discharged with a diagnosis of severe tonsillitis.
Despite further antibiotics from his GP for a suspected chest infection, Yusuf’s condition deteriorated. His family called an ambulance and insisted he be taken to Sheffield Children’s Hospital, where he was admitted to intensive care on 21 November 2022.
He developed pneumonia, sepsis, multi-organ failure, and suffered several cardiac arrests.
Yusuf tragically died on 23 November 2022.
A review into his death followed.
Key findings from the report
Led by Peter Carter, former General Secretary of the Royal College of Nursing, the 139-page report found:
“Our primary finding is that the parental concerns, particularly the mother’s instinct that her child was unwell, were repeatedly not addressed across services.
“A reliance on clinical metrics over caregiver insight caused distress for the family.
“This led to a lack of shared decision-making and there was limited evidence of collaborative discussions with Yusuf’s family around clinical decisions, leading to a sense of exclusion and reduced trust in care plans.”
The report also outlined 23 separate healthcare contacts across four organisations “with no single, co-ordinated record or oversight, contributing to fragmented and disjointed care”.
The report found that staff also failed to properly document critical procedures at Sheffield Children’s Hospital, including administration of intravenous antibiotics, cannula insertions, and fixation.
The report concluded that while it was impossible to determine whether earlier intervention would have saved Yusuf’s life, the care he received fell short of expected standards.
Family response and calls for accountability
Yusuf’s mother, Soniya Ahmed, delivered a powerful statement following the report’s release, describing the pain of watching her son suffer without adequate care. She cited 13 missed opportunities to escalate his treatment and called for accountability and lasting change.
Government and NHS response
Rotherham MP Sarah Champion and Health Secretary Wes Streeting have both backed the family’s call for a full inquest.
Mr Streeting acknowledged that Yusuf’s death was the result of “tragic failings” and pledged that the NHS would implement the report’s recommendations, including:
- Training around communicating with caregivers and recognising and responding to “diverse cultural needs”.
- The health service is to record parental concerns and review workloads for ambulance crews.
- Review training around cannula, vascular access insertion, and intravenous therapy.
Dr David Crichton, chief medical officer at NHS South Yorkshire, accepted the report’s recommendations in full.
Comment
Yusuf’s story is a heartbreaking example of what can go wrong when families’ concerns aren’t heard.
The report shows that important signs were missed, and care was not properly communicated between services. It’s clear that changes are needed to make sure parents and carers are heard, and that hospitals and healthcare teams work better together.
No family should have to go through what Yusuf’s did, and this case reiterates that listening to caregivers isn’t optional; it’s essential.
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Sadiyah Caratella is a Paralegal in our expert Medical Negligence team, which has been ranked in tier one by the independently researched publication, The Legal 500.
If you have any questions in relation to the subjects discussed in this article, then please get in touch with Sadiyah or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
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