Prevention of future deaths report: Adam Hussain (8 January 2026)

Summary

Adam Hussain died from complicated appendicitis with perforation and peritonitis on 16 May 2025. This illness developing over a three day period, with worsening abdominal pain, vomiting and clear evidence of sepsis on the day prior to his final admission, which followed a cardiac arrest at home.

The Coroner in their report states that there were many opportunities missed by the East Midlands Ambulance Service (EMAS) and by the Nottingham Emergency Medical Service (NEMS) to recognise the severity of his illness, and to ensure a face to face assessment, most particularly and obviously on 14 May, the day prior to his collapse at home on 15 May. No organisation with whom there was contact, recognised that there were repeated calls for assistance over the days prior to his death.

Content

The Coroner lists matters of concern in this case as follows:

• The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response.
• There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
• Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent.
• Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation.
• There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS.