Independent Patient Safety Investigation Report critical of care following five-year-old Yusuf Mahmud Nazir’s death at Sheffield Children’s Hospital

Press statement for release after lifting of embargo at 09:30am on 31 July 2025

Today the second investigation report was published following Yusuf Mahmud Nazir’s death. The link to the report can be found here.

The report is critical about the failure to listen to Yusuf’s mother after she repeatedly raised concerns about Yusuf’s health at their GP Surgery on 14 November and 18 November 2022, Rotherham General Hospital on 15/16 November 2022, with Yorkshire Ambulance Service on 18 November 2022 and at Sheffield Children’s Hospital between 18-23 November 2022.

The new report is critical of the care and treatment Yusuf received on Ward 4 at Sheffield Children’s Hospital between the evening of Friday 18 November 2022 until Yusuf was transferred to the Paediatric Critical Care Unit on Monday 21 November 2022.  These failures can be summarised as:

1. Inconsistent clinical assessments.
2. Poor cannulation care leading to the compromise of Yusuf’s I/V antibiotics.
3. Poor management and administration of medication.
4. Poor documentation and record keeping.
5. Inadequate training of staff.
6. Lapses in Paediatric Escalation Warning System (PEWS) escalation.
7. Poor Visual Infusion Phlebitis (VIP) score and pump pressure recording.
8. Staff resourcing at the weekend with a lack of senior decision makers/ consultants physically present and a wait and see approach.
9. Non-compliance with Royal College of Paediatrics and Child Health (RCPCH) and Royal College of Nursing (RCN) guidelines.
10. 23 contacts over the course of Yusuf’s care with little continuity of care.
11. Several references that the standard of care fell below what should have been expected of staff at Sheffield Children’s Hospital.
12. The failure to complete a post mortem after death.

Sixteen recommendations have been made, including national recommendations.

The family is now calling on each organisation to learn lessons from Yusuf’s death and implement all recommendations immediately. 

Yusuf’s family still continue to have many unanswered questions and want an inquest opened into his death.  They will be writing to the Coroner shortly to request this.

Yusuf’s mother, Soniya Ahmed states:

The failings identified are truly shocking. 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. This is why we want an inquest.

Yusuf’s Uncle, Zaheer Ahmed states:

We do not understand how our healthy and bright Yusuf could have died. Despite the report’s findings, we still believe that if Yusuf was admitted to Rotherham General Hospital and received I/V antibiotics that he would still be here today.

We thought that Yusuf was in the best place at Sheffield Children’s Hospital without knowing the outrageous failures that have now been revealed with this second investigation. We now want to meet with the Sheffield Children’s Hospital about the recommendations and changes they are making.

We miss Yusuf every single day.

Partner Anna Thwaites at Bindmans LLP, who has represented the family from the beginning with Counsel Adam Wagner KC from Doughty Street Chambers states:

This has been a long and difficult journey for the family. They knew there were issues with Yusuf’s care and treatment from the beginning.

The second investigation revealed new failings, but Yusuf’s family had to wait over 2.5 years for these be revealed; the wait has been agonising for them.

Whilst the report answers some of the family’s questions, many more questions remained unanswered.

Yusuf’s family also wish to ensure that the recommendations in the report are followed through and implemented in full and an inquest is opened. This was after serious systemic failures have been identified in the report.

The family calls for action and change. The family do not want Yusuf’s death to be in vain. Another child cannot be failed.