Abdirahman Afrah · Prevention of Future Deaths report

On the 13 June 2024 I commenced an investigation into the death of Abdirahman Abdirizahq Afrah, aged 17 at the time of his death. The investigation concluded at the end of the inquest on 15 May 2025 with a conclusion of natural causes.

Abdirahman Afrah began to suffer from chest pain, associated with a cough, from the very early hours of the 3 June 2024. At around 2330 on the 3 June 2024 he attended Newham University Hospital A&E, on the direction of a NHS 111 clinical adviser. He notified the triage nurse of severe chest pain radiating to the left arm and shoulder. He had a tachycardia of 130 beats per minute, but other vital signs were normal. An ECG was carried out which showed a sinus tachycardia and P pulmonale. Venous blood gases showed an abnormal base excess, indicating a compensated metabolic acidosis. Abdirahman was given two lots of painkillers whilst in the A&E department, but his pain continued to be severe. After around 3 hours of waiting, Abdirahman asked to lie down due to his level of pain. He was told that there were no beds available and that he would have to wait a further 4 hours or so. He notified the nurse that he would have to leave, to be able to lie down to relieve the pain. The nurse advised him that he could leave. He was not seen by a doctor before leaving the department. A doctor from A&E called him the following afternoon to tell him to return to the A&E department for a doctor to explain the results of the tests. He raised concerns about the waiting times and said that he was seeing his GP later the same afternoon. The importance of returning to hospital was not explained clearly to him. Abdirahman did attend his GP practice at around 1630 on 4 June 2024. He was seen by a physician's associate who did not have the hospital results available to her. Abdirahman was clinically stable at the consultation. He was advised by the physician's associate to return to the emergency department to discuss his results. It is unlikely that he was advised to return with any sense of urgency. At around 8pm on the 4 June 2024, Abdirahman suffered a collapse in his home address. Emergency services were called and he was urgently conveyed back to Newham University Hospital. Sadly, all life-saving efforts at this time were unsuccessful. Abdirahman's life was pronounced extinct at Newham University Hospital at 2145 on 4 June 2024. Abdirahman died as a result of bleeding caused by a pulmonary vascular malformation. There was a missed opportunity to provide further investigations and treatment to him when he attended hospital on the late evening of the 3 June 2024. The evidence did not however reveal that such investigation and treatment would, on the balance of probabilities, have prevented his death

1. The inquest heard that waiting times to be seen in Majors A&E at Newham University Hospital could sometimes be between 9 to 14 hours. Many patients are unable to tolerate such long waits and leave the department before being seen.
2. There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage. Without such frontloading of care, patients like Abdirahman who might compensate right up to the point of collapse, might be missed again.
3. When the doctor called Abdirahman the following afternoon, she did not have all of the relevant clinical information to hand. She was not aware of the compensated metabolic acidosis. It is unlikely that she advised Abdirahman of the importance of returning to the hospital. It is foreseeable that patients may be reticent to return to A&E, because of the lengthy waits, so doctors making the call to patients who have left, should be fully informed about the clinical condition and risks. The risk of not returning should be made very clear.
4. Abdirahman was 17 years old. He declined to return to A&E. There was no direct discussion with a responsible parent about the need to return to A&E.
5. When Abdirahman stated that he would be seeing his GP later that afternoon, he asked for the relevant results to be sent to the GP. Neither the results, nor the discharge summary were sent to the GP in time for the appointment. The inquest heard that the A&E doctor did not know how to share such information with the GP.