An inquest has heard how a 23-year-old Nottingham man who made numerous pleas for help as he became severely unwell could have survived if he had been taken to hospital sooner.
Adam Hussain from Clifton died on 16 May 2025, due to untreated appendicitis leading to perforation, septic shock and organ failure. This was directly contributed to by a breakdown in communication between two key Nottinghamshire-based healthcare services, which did not identify and escalate Adam’s deteriorating condition fast enough.
Following a three-day inquest at Nottingham Coroners’ Court, which concluded on Friday, 12 December, assistant coroner Elizabeth Didcock confirmed there were “many missed opportunities” by East Midlands Ambulance Service (EMAS) and Nottingham Emergency Medical Services (NEMS) to treat Adam sooner.
The three-day hearing at Nottingham Coroner’s Court heard that Adam and his family made repeated calls to emergency services between 12 and 14 May 2025 as his condition deteriorated. Despite worsening symptoms including severe abdominal pain, persistent vomiting, dizziness, inability to walk and slurred speech, Adam was not given a face-to-face assessment when he should have been, and red flag symptoms were crucially missed.
Timeline of events
- On May 12, Adam called 999 complaining about abdominal pain and vomiting. Despite needing face-to-face assessment, he was advised to take pain relief and was told a GP would call him within 24 hours – this advice was incorrect, and he should have been told to call his doctor.
- On the same day, two more calls to 999 were made, first by Adam, explaining that the pain was worse and he was struggling to breathe. He was advised to visit the walk-in centre, which he did, and was discharged by midday.
- Later that afternoon, Adam’s brother Qasim rang 999 again, describing Adam’s pain as ‘all over his body’ and that he was shaking, struggling to breathe and showing confusion. He was told again to visit the walk-in centre, but having already been, the call was ended.
- On May 14, Adam called 111. He reported blood in his urine, feeling faint and like he was going to collapse, ongoing severe abdominal pain and dark coloured vomit. He was transferred to a clinical advisor who, following assessment, advised that an ambulance would be arranged.
- Unfortunately, when this request reached EMAS, only some of the notes were considered before the call was transferred onwards to NEMS for assessment, which should not have happened.
- During the afternoon of May 14, Adam had another telephone consultation with NEMS. There was no exploration of his fever symptoms nor the extent of his vomiting.
- Adam called 999 again during the evening of 14 May. He couldn’t stand, walk or sleep because of his symptoms and had heart palpitations. He was advised that a clinician would call for a further assessment, and the call was transferred to NEMS.
- A further NEMS assessment took place on the night of 14 May. Adam was notably breathless, had slurred speech, appeared muddled and reported falling over when he tried to walk. He was advised to seek further advice from his GP or 111 the next day if his symptoms didn’t improve.
- On May 15, Adam’s brother called 111 again, and this led to an ambulance being dispatched. Whilst the paramedics were in attendance, he went into cardiac arrest at his home and was transferred to Queen’s Medical Centre. However, despite emergency surgery, Adam’s condition did not improve.
- On May 16, the decision was made to turn off his life support.
Evidence was heard from key witnesses involved in Adam’s final days, and the court heard recordings taken from his 999 calls. The coroner delivered a narrative verdict, concluding:
”The number of emergency calls from 12th to the 14th [of May] were evidence of Adam’s persistent and worsening symptoms and therefore the need for face-to-face assessment and necessary treatment. This was not recognized by EMAS, nor by the NEMS service.
“Had Adam been seen face-to-face on 14 May, it is very likely that the intra-abdominal sepsis would have been recognised and treatment provided, likely leading to him surviving what is a treatable condition in a previously fit and well young man.”
The inquest heard evidence that pointed to serious concerns about the care provided by both EMAS and NEMS. Concerns were also raised about the limited information passed between healthcare organisations and a lack of consideration of key information when consulting with Adam during the calls.
The Coroner heard detailed evidence from both NEMS and EMAS about the steps taken to prevent similar deaths in the future. As a result, the Coroner issued a Prevention of Future Deaths Report to both organisations and shared it with NHS England to ensure oversight of the concerns raised.
It was noted that NEMS had carried out a detailed review of Adam’s care and put in place a robust internal action plan. NEMS also attempted to work with EMAS to address wider issues between the two organisations. However, EMAS did not appear to have carried out a similar review or identified risks within its own organisation that could affect patient safety. It is hoped that following the Coroner’s report, the healthcare providers will work collaboratively to implement system-wide changes.
Adam’s brother, Qasim Hussain, gave the following statement:
“Since losing Adam, we have been trying to make sense of what happened, and come to terms with his sudden and unexpected passing. It has been very hard for us all, especially knowing that Adam could have been saved if his condition had been treated sooner.
“Adam tried many times to get help from both the ambulance and out of hours services – I witnessed firsthand how quickly he became unwell and how his symptoms worsened. We phoned for medical attention many times but no one came, despite Adam telling them he was too unwell to stand, never mind make his own way to the hospital. Adam deserved better. Whilst nothing can bring Adam back, I hope that there will be serious learning by the medical professionals involved and changes made to prevent this happening again to someone else.
“Adam was the eldest of four siblings and throughout his life took on the responsibility of looking out for his family. Adam showed resilience, strength and courage through the challenges and difficulties he faced in his life. He was very ambitious and inspired those around him. He earned a full scholarship to a private high school and at 18, he got his own place, balancing work and psychology studies. He used to impress employers and secure sales jobs without difficulty. There was nobody I knew who had more confidence than him.
“Adam and I were very close. Some of my favourite memories were when I used to visit him at his flat and spend our evenings together – we used to laugh a lot, eat together and spend time playing games or watching movies. Whenever we are together now as siblings, it feels lonely and empty without our brother.
“I know that my brother will always be remembered by those close to him for his intelligence and unwavering personality. He was a truly extraordinary person, a loving brother and a loyal friend. His death has left an unimaginable void in our lives, but he will always be remembered with happiness and love.”
Shrdha Kapoor, inquest specialist and solicitor in our Medical Negligence team, has been assisting Adam’s family through the inquest process, alongside barrister Edward James, from Ropewalk Chambers.
She said:
“The past seven months have been an incredibly difficult time for Adam’s family and loved ones.
“The inquest has heard evidence that the care Adam received did not meet expected standards and there were sadly too many missed opportunities to recognise how unwell Adam was and to escalate this appropriately. It is deeply upsetting to learn that with earlier hospital admission, Adam’s condition would have been treatable, and he would have survived.
“We very much welcome the Coroner’s Prevention of Future Deaths report, especially as there has been another tragic death of young man earlier this year that raised similar concerns. We hope with support from the Coroner and oversight by NHS England, this report will lead to meaningful change and improved collaboration between these organisations to prevent tragedies like this happening in the future.
“Whilst the inquest has been understandably difficult for the Hussain family, I commend their bravery and resilience throughout the process to get the answers they needed. I hope that the family are now able to find some peace and remember happier times with Adam.”