A mother’s instinct that her child was unwell was “repeatedly not addressed across services”, a report on the death of a five-year-old boy has concluded after he was sent home from A&E.
Yusuf Mahmud Nazir died on 23 November 2022, eight days after he was seen at Rotherham hospital and sent home with antibiotics.
A report on Yusuf’s case in October 2023, by independent consultants and published by NHS South Yorkshire, found his care was appropriate and “an admission was not clinically required”, but this was rejected by his family.
Yusuf’s uncle Zaheer Ahmed has always said they were told “there are no beds and not enough doctors” in the emergency department, and that Yusuf should have been admitted and given intravenous antibiotics in Rotherham.
A report published on Thursday by NHS England said in its conclusions: “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.”
Yusuf, who had asthma, was taken to the GP with a sore throat and feeling unwell on 15 November. He was prescribed antibiotics by an advanced nurse practitioner.
Later that evening, his parents took him to Rotherham hospital urgent & emergency care centre (UECC), where he was seen in the early hours of the morning after a six-hour wait.
Yusuf was discharged with a diagnosis of severe tonsillitis and an extended prescription of antibiotics.
Two days later Yusuf was given further antibiotics by his GP for a possible chest infection, but his family became so concerned they called an ambulance and insisted the paramedics take him to Sheffield children’s hospital rather than Rotherham.
Yusuf was admitted to the intensive care unit on 21 November but developed multi-organ failure and suffered several cardiac arrests, which he did not survive.
The 2023 report said there was only one doctor in the paediatric UECC on 15 November and, after midnight, that medic was responsible for covering adults and children.
It added that the doctor who saw Yusuf was an experienced UECC doctor who would not have needed to refer to a paediatrician to admit him.