A new report into the death of a five-year-old boy after he was sent home from A&E has concluded that his mother’s instinct that her child was unwell was “repeatedly not addressed across services”.
Yusuf Mahmud Nazir died on November 23 2022, eight days after he was seen at Rotherham Hospital and sent home with antibiotics.
A report into 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 new 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 November 15. 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 November 21 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 November 15 and, after midnight, that medic was responsible for covering adults and children.
It added that the doctor who saw Yusuf is an experienced UECC doctor who would not have needed to refer to a paediatrician to admit him.
