Yusuf Mahmud Nazir: Boy dies after being sent home from Accident and Emergency because there were 'no beds'
A five-year-old boy died after being sent home from A&E, despite his mother pleading for help.
Now, a new report has concluded that her concerns were repeatedly ignored by NHS staff.
Yusuf Mahmud Nazir died at Sheffield Children’s Hospital on 23 November 2022, eight days after first being taken to Rotherham Hospital, where he was diagnosed with severe tonsillitis and sent home with antibiotics.
His mother, Soniya Ahmed, has described the trauma of watching her son struggle to breathe and says she hears his voice every night: “Mummy, I can’t breathe, I can’t breathe, I really can’t.”
A new independent report published on Thursday (July 31) found that health professionals failed to take the family's concerns seriously. “Our primary finding is that the parental concerns, particularly the mother’s instinct that her child was unwell, were repeatedly not addressed across services,” the report said. “A reliance on clinical metrics over caregiver insight caused distress for the family.”
Yusuf, who had asthma, had 23 separate contacts with healthcare professionals across four different organisations. “There was no single, co-ordinated record or oversight,” the report noted, “contributing to fragmented and disjointed care.”
Ms 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. 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.”
She added: “Yusuf deserved better. Every child does. I will never stop speaking his name. I will never stop fighting for him. 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 was first taken to a GP on November 15 and prescribed antibiotics. That same evening, his parents took him to Rotherham Hospital’s urgent care centre, where they waited six hours. He was discharged with more antibiotics and a diagnosis of tonsillitis. Over the next few days, his condition worsened.
His uncle Zaheer Ahmed said the family had begged staff to admit Yusuf but were told “there are no beds and not enough doctors.” He said: “Despite the report’s findings, we still believe that if Yusuf was admitted to Rotherham General Hospital and received IV antibiotics, that he would still be here today.”
On November 21, an ambulance took Yusuf to Sheffield Children’s Hospital. He was admitted to intensive care, but his condition deteriorated rapidly. He died two days later after suffering multiple cardiac arrests. The report found Yusuf had pneumonia and sepsis, but said “no causative agent” was found.
While the October 2023 report previously concluded that admission at Rotherham “was not clinically required,” the new review - led by former Royal College of Nursing chief Peter Carter—sharply criticises the lack of communication, shared decision-making, and outdated equipment used in Yusuf’s care. His family were particularly distressed by findings that Sheffield Children’s Hospital used an outdated cannula method that deprived Yusuf of necessary medication.
Health Secretary Wes Streeting said: “There are no excuses for the tragic failings in the lead-up to Yusuf’s death… This independent report reveals their concerns were repeatedly not addressed across NHS services.”
Professor Aidan Fowler, NHS England’s National Director of Patient Safety, said: “We accept the report’s recommendations… the failure to listen to and act on the concerns of Yusuf’s family by multiple NHS services is unacceptable.”
Dr Jeff Perring from Sheffield Children’s NHS Foundation Trust said: “We are dedicated to delivering the improvements outlined in the report’s recommendations.” Dr Jo Beahan of Rotherham NHS Foundation Trust added: “We have taken steps to address the recommendation and also the concerns raised by Yusuf’s family.”
Yusuf’s family continues to demand a full inquest, saying only a judicial process can reveal who is ultimately responsible for his death. His uncle concluded: “We miss Yusuf every single day.”