The mother of a five-year-old boy who died after he was sent home from A&E has said she hears her son every night saying “Mummy, I can’t breathe”, as a report concluded she was not listened to by health professionals.
Yusuf Mahmud Nazir died at Sheffield Children’s Hospital on November 23 2022, eight days after he was seen at Rotherham Hospital and sent home with antibiotics.
A fresh report into Yusuf’s care was published on Thursday with a range of recommendations for the NHS, but his family said there are still many unanswered questions and have demanded an inquest into his death.
The report 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.”
Speaking at a press conference in Rotherham, Yusuf’s mother, Soniya Ahmed, said: “For the medical staff there are lessons to be learnt from this tragedy, but for us, our life, Yusuf has been taken away from us in the most horrific way.
“Every night when I close my eyes I hear Yusuf’s helpless voice in my ears saying, ‘Mummy, I can’t breathe, I can’t breathe, I really can’t’.
“And the image of him being handed over to me after his life ended, as though someone has torn my heart out and placed it in my hands.”
Ms Ahmed choked back tears as she said: “Along with these failings, there is still uncertainty on his cause of death.
“Yusuf deserved better. Every child does. I will never stop speaking his name. I will never stop fighting for him. I fight for every child failed by the NHS.
“We demand accountability, we demand change.
“We want to know how our son has died and who is responsible, and the only way we will get these answers is with an inquest. The family demand an inquest.”
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.
Yusuf, who had asthma, was taken to a GP with a sore throat and feeling unwell on November 15. He was prescribed antibiotics by an advanced nurse practitioner.
Later that evening, his parents took him to Rotherham Hospital urgent and emergency care centre (UECC) where he was seen in the early hours of the morning after a six-hour wait.
He 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 November 21 but developed multi-organ failure and suffered several cardiac arrests which he did not survive.
A report into his case in October 2023, produced 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.
The fresh report by Peter Carter, former general secretary of the Royal College of Nursing, said it was agreed that Yusuf had pneumonia and sepsis, which led to respiratory failure and his death, but “no causative agent” could be found.
It said: “It is impossible to make a statement on whether (intravenous) antibiotics or earlier detection would have prevented Yusuf’s death.
“We understand that this is not the information that the family obtained initially and appreciate how this difference of professional opinion has led to confusion and emotional distress for the family.”
The report said Yusuf had 23 separate healthcare contacts across four organisations “with no single, co-ordinated record or oversight, contributing to fragmented and disjointed care”.
The family said they were most surprised by the report’s findings in relation to Sheffield Children’s Hospital, including that it used an outdated cannula method which deprived Yusuf of drugs he needed.
But the report also said it asked experts to assess whether there was “any clinical evidence to suggest that Yusuf’s earlier admission to (Rotherham Hospital) for IV antibiotics, would have possibly prevented Yusuf’s death”, and the reply was: “I do not believe it would have done.”
Mr Ahmed said on Thursday: “Despite the report’s findings, we still believe that if Yusuf was admitted to Rotherham General Hospital and has received IV antibiotics, that he would still be here today.”
He added: “We miss Yusuf every single day”.
Health Secretary Wes Streeting said: “There are no excuses for the tragic failings in the lead-up to Yusuf’s death and I know first-hand how hard it has been for his family to live without the answers they deserve.
“This independent report reveals their concerns were repeatedly not addressed across NHS services.
“It is now the responsibility of the NHS to implement the recommendations in this report so that the family can at least take small comfort in knowing that because of Yusuf, and thanks to Yusuf, children will be safer and better cared for in the future, but I know that really is of no consolation for a loving family living with the unimaginable pain of losing a lovely little boy in these awful circumstances.”
Professor Aidan Fowler, national director of patient safety in England, said: “Our thoughts and sincere condolences remain with the family of Yusuf Nazir who have suffered an unbearable loss.
“We accept the report’s recommendations and acknowledge the issues this independent investigation has uncovered, particularly the failure to listen to and act on the concerns of Yusuf’s family by multiple NHS services, which is unacceptable.”
Dr Jeff Perring, executive medical director at Sheffield Children’s NHS Foundation Trust, said: “The report identifies important areas for learning and improvement, not only for us at Sheffield Children’s but also across the wider healthcare system.
“We are dedicated to delivering the improvements outlined in the report’s recommendations.”
Dr Jo Beahan, medical director at Rotherham NHS Foundation Trust, said: “Our deepest sympathies remain with Yusuf’s family following such a sad loss of a loved family member. We fully co-operated with this investigation into Yusuf’s care.
“We have taken steps to address the recommendation and also the concerns raised by Yusuf’s family. Our thoughts continue to be with Yusuf’s family.”
