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An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir: Published July 2025

North East and Yorkshire Published 01 Jul 2025 Subject Patient S

Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud Nazir Appendices The report has also been published on the following websites:

Report PDF NHS England Source
Jump to 17 recommendations

Acceptance status

Per recommendation
No Response Published
17
Total recommendations
17
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

17 total
1 Healthcare System No Response Published
Recommendation
Improve recognition of documentation of differential diagnosis
1 Healthcare System No Response Published
Recommendation
Systematically embed caregiver concerns into clinical assessment and decision-making.
2 The Rotherham NHS Foundation Trust (TRFT) No Response Published
Recommendation
Introduce structured documentation protocols for recording parental concerns.
3 Yorkshire Ambulance Service (YAS) No Response Published
Recommendation
Address the impact of work pressures, including rest breaks and downtime.
3 Yorkshire Ambulance Service (YAS) No Response Published
Recommendation
Strengthen cultural competence, psychological safety, and civility in practice.
3 Yorkshire Ambulance Service (YAS) No Response Published
Recommendation
Clarify processes around patient choice and communication.
4 Sheffield Children’s Hospital (SCH) No Response Published
Recommendation
Implement comprehensive vascular access guidelines, including cannula insertion and fixation
4 Sheffield Children’s Hospital (SCH) No Response Published
Recommendation
Conduct a medicines management policy review.
4 Sheffield Children’s Hospital (SCH) No Response Published
Recommendation
Review and standardise the prescription chart format.
4 Sheffield Children’s Hospital (SCH) No Response Published
Recommendation
Enhance PEWS training, with clear escalation pathways.
5 NIHR No Response Published
Recommendation
Support NIHR research into: How caregiver concerns are raised, received, and acted upon.
5 NIHR No Response Published
Recommendation
Support NIHR research into: Tonsillitis complications and the management of secondary infections
6 Healthcare Providers No Response Published
Recommendation
To ensure families are informed that when their children are on ventilators, they may still be able to hear, and should be encouraged to talk to and interact with them
6 Healthcare Providers No Response Published
Recommendation
To ensure that any items such as clothing or equipment can be saved so families can keep as memories when a child dies.
7 National Healthcare System No Response Published
Recommendation
Consultant Oversight: Explore a national workforce plan to support sustainable consultant-led oversight, including realistic weekend cover models in paediatrics.
7 National Healthcare System No Response Published
Recommendation
Parental Access to Records: Consider national guidance on giving parents visibility of their child’s medical records during admission, similar to maternity-held notes.
7 National Healthcare System No Response Published
Recommendation
Paper Record Use: Review the continued use of paper-based records in paediatric care, due to potential risks to continuity and safety.