Independent Patient Safety Investigation (IPSI) report of Yusuf Mahmud Nazir (31 July 2025)

Summary

Following the tragic death of Yusuf Nazir in November 2022, an independent patient safety investigation was commissioned by NHS England, involving a number of organisations.

Content

The investigation was commissioned by NHS England in response to concerns raised by the family regarding the care and treatment of Yusuf across multiple clinical settings, before his death on 23 November 2022. Yusuf’s family raised the following concerns

• Care and treatment received at the The Surgery General Practice surgery on 15th and 18th November 2022
• Care and treatment received during attendance at TRFT Emergency Department on 15 – 16 November 2022
• Care and treatment received during admission at SCH on 18 November – 23 November 2022
• Care and treatment received by YAS on 18 November 2022.

Summary of findings

Although there is agreement that Yusuf had pneumonia and sepsis, which led to respiratory failure and his death, there was no causative agent which could be found on laboratory testing. It is impossible to make a statement on whether IV antibiotics or earlier detection would have prevented Yusuf's death. t is understood that this is not the information that the family obtained initially and appreciate how this difference of professional opinion has led to confusion and emotional distress for the family.

Yusuf’s death followed a prolonged and traumatic resuscitation attempt, and the impact underscored the emotional and psychological toll on both the family and professionals involved. The primary finding is that the parental concerns, particularly the mother’s instinct that her child was unwell, were repeatedly not addressed across services. A reliance on clinical metrics over caregiver insight caused distress for the family. This led to a lack of shared decision-making and there was limited evidence of collaborative discussions with Yusuf’s family around clinical decisions, leading to a sense of exclusion and reduced trust in care plans.

Yusuf had 23 separate healthcare contacts, across four organisations with no single, coordinated record or oversight, contributing to fragmented and disjointed care. Many of the healthcare professionals acted primarily in triage roles which diminished parental voices.

Inconsistent clinical assessment of the respiratory system of tonsilitis and between organisations and minimal references to differential diagnosis, meant while some vital signs were recorded, the clinical assessments were inconsistent leading to difficulties in comparing Yusuf over time, with insufficient interpretation of parameters such as respiratory rate and oxygen saturation and a focus on tonsillitis to the exclusion of alternative explanations.

Areas of improvement were raised about the care and treatment of Yusuf during admission to Sheffield Children’s Hospital from the 18th to the 23rd November 2022 in relation to in cannula care and maintenance, medication administration and poor documentation, the use of Paediatric Early Warning Scores (PEWS), and missed opportunities to escalate with lack of visibility of consultant oversight. This occurred over a weekend, highlighting the reduced resourcing often seen during this period, including limited workforce availability and fewer senior decision-makers, which is a challenge recognised nationally.

While the response to acute deterioration was excellent and substantive, routine care prior to crisis was marked by a ‘wait and see’ approach that failed to pre-empt worsening symptoms.