Yusuf Nazir: New report examines death of boy who was sent home from hospital due to a 'lack of beds'
Yusuf Nazir died in November 2022. His mother Soniya had rushed her son to Rotherham Hospital's A&E, only to be told "there were no beds available".
Yusuf was eventually seen by a doctor but then sent home. Soniya says the doctor told her that "Yusuf had the worst case of tonsillitis he had ever seen".
But the child's health continued to deteriorate, and his desperately worried mother called an ambulance to rush him to the nearby specialist children's hospital in Sheffield.
It was here, the report says, that a number of critical interventions were missed. Yusuf's family say that, if doctors had acted sooner, he would still be alive.
Speaking in her first interview since Yusuf's death, Soniya described the panic she felt as a mother watching her son "dying in front of her eyes".
"I carried Yusuf to the nurse, floppy with his eyes rolled back, struggling to breathe, myself to the nurse," Soniya said.
"She said: 'We're too busy, we can't get a doctor, you'll have to wait.'"
Other patients in the waiting room intervened when they saw Yusuf gasping for air and struggling to breathe, but they were told Yusuf's mother should approach the nurses herself if she was concerned.
This second independent report was backed by Wes Streeting when he was shadow health secretary.
A previous internal NHS report found no wrongdoing on the part of Rotherham Hospital. The family have described that report as a "whitewash".
Their claim will be supported by this second report, which says: "It's clear that across all settings - primary care, pre-hospital, emergency and inpatient - the healthcare system failed to truly hear the family's voice."
It also says staff should have listened to the "mother's instinct".
"I knew he was very, very poorly, he was struggling to breath, he was lethargic, he was floppy," Soniya told Sky News.
"I knew that something's not right before they even escalated it to the ICU. I knew he was very poorly but no one else picked it up."
The health secretary told Sky News: "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."
Part of the report's key findings shows Yusuf had 23 separate healthcare contacts across four NHS organisations that were responsible for his care, but there was no coordinated record or oversight.
It found the clinical assessments that were made were inconsistent and led to difficulties in comparing his condition over time. Routine care prior to his crisis was marked by a wait-and-see approach that failed to pre-empt worsening conditions.
It also recorded clinical staff at Sheffield used an outdated cannula method that failed to give Yusuf potentially life-saving drugs.
Soniya says she pointed out the leaking cannula to Yusuf's nurses, but her concerns were brushed aside.
"The cannula burst and the whole bed was full of his medication and blood on the morning he went to the ICU, the whole weekend he'd not had that medication," she said.
"He'd have been in pain and he wouldn't have been getting any better if he wasn't having the medication. And I think that's the reason Yusuf's not here anymore.
"From the moment he was in Sheffield Children's Hospital until the end I think he didn't get any treatment, it was just like him being at home."
Soniya says she welcomes the report's findings that show Yusuf did not get the care he needed - but the investigation does not find a cause of death or apportion blame.
The investigation has made national recommendations, including consultant-led oversight on weekends and giving parents visibility of their child's medical records.
Sky News has closely followed the family's fight for answers since first reporting on Yusuf's case, two days after he died.
1:04
Dr Jeff Perring, executive medical director at Sheffield Children's NHS Foundation Trust, said: "We recognise the profound loss felt by Yusuf's family and those who loved him.
"We will be reviewing the recommendations of the report and taking those forward through education, guidance, policy and training to deliver the best care for our children, young people and families."
"We want change," Soniya says. "We want this not to happen to any other child. Because if they don't change, there's going to be another child and another mother sat here telling you the same story."
Dr Jo Beahan, medical director at The Rotherham NHS Foundation Trust, said: "Our deepest sympathies remain with Yusuf's family following such a sad loss of a loved family member.
"Since November 2022, we have taken steps to address the concern relating to Yusuf's care which includes listening to the concerns of parents and carers. Our thoughts continue to be with Yusuf's family."
Professor Aidan Fowler, national director of patient safety in England, said: "Our sympathies remain with Yusuf's family, and we acknowledge the heavy toll this investigation has placed on them - while grieving an unimaginable loss.
"Following publication of the final report today, we will respond on the findings and how we will be taking forward the recommendations in the report to ensure there are continuing improvements in patient safety and care for children across NHS hospitals and services in the future."
The Nazir family's fight is not over. This report cannot confirm Yusuf's cause of death, or say if his life could have been saved with better care.
It is why Soniya is demanding a coroner's inquest into her son's death: so that she and her family can finally have closure.
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