A report into the death of a five-year-old boy sent home from A&E has called for national guidance to take into account parents’ intuition that “something feels very wrong” about their child. Yusuf Mahmud Nazir died of pneumonia and sepsis at Sheffield children’s hospital on 23 November 2022, almost a week after his parents first raised concerns.
The independent patient safety investigation (IPSI) report, commissioned by NHS England, found that clinicians failed to listen to the concerns of Yusuf’s mother, Soniya Ahmed, instead relying solely on data that suggested he was not seriously ill. The report recommended that caregivers’ concerns be treated as a “legitimate and vital form of evidence”.
Dr Peter Carter, the report author, stated: “The system is not designed to capture ‘something feels very wrong’ as an input, and thus a gap opens between family and clinicians.” The report found 12 failings, including poor communication and record-keeping, and made 16 recommendations.
Yusuf, who had asthma, was taken to the GP on 15 November 2022 and later to Rotherham hospital, where he was discharged with a diagnosis of severe tonsillitis. Despite further treatment, his condition deteriorated, and he was admitted to intensive care on 21 November, but died after multiple cardiac arrests.
Ahmed said: “The failings identified are truly shocking. Yusuf deserved better; every child does.” The family has written to the coroner requesting an inquest. The report comes as Martha’s rule, giving parents the right to an urgent second opinion, is being piloted in hospitals.
