This report is being sent to: Department for Health and Social Care, Ministry of Housing, Communities and Local Government
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO:
Department of Health and Social Care (DHSC) Ministry of Housing, Communities and Local Government (MHCLG)
1
CORONER
I am Dr Anton van Dellen, HM Assistant Coroner, for the coroner area of West London
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION AND INQUEST
An investigation was commenced into the death of Mohamed Abdisamad, aged 6 months. The investigation concluded on 8 October 2025. The conclusion of the jury in the inquest was: Complications following Non-Therapeutic Male Circumcision (NTMC) The medical cause of death was 1a Invasive Streptococcus pyogenes infection following male circumcision (12/02/23)
4
CIRCUMSTANCE OF THE DEATH
On 12 February 2023 at 3:00pm, Mohamed Abdisamad underwent a Non-Therapeutic Male Circumcision (NTMC) by a circumciser who was recommended to Mohamed’s parents and requested by them to perform the procedure on their son. Following the procedure, the wound appeared to be healing well. However, 3 to 4 days following the procedure, symptoms of illness started to manifest. On Sunday 19 February, Mohamed’s mother contacted the emergency services due to concerns about Mohamed’s deteriorating condition. Upon presentation to the paramedic, a decision was made to transport Mohamed to Hillingdon Hospital by an ambulance and, during the journey, Mohamed had a cardiorespiratory arrest. Despite the resuscitation efforts by the paramedics and hospital staff, Mohamed was declared dead at 23:55 on 19 February 2023.
5
CORONER’S CONCERNS
During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Any individual may conduct a Non-Therapeutic Male Circumcision (NTMC) without any prior training or any Continuing Professional Development (CDP), There is no system of external accreditation and/or registration for individuals who conduct a Non-Therapeutic Male Circumcisions (NTMC). There is no requirement for any record keeping for individuals who undergo a Non-Therapeutic Male Circumcisions (NTMC). There is no system for consent to be taken prior to a Non-Therapeutic Male Circumcisions (NTMC). There is no requirement for any infection control measures for a Non-Therapeutic Male Circumcisions (NTMC). There are no requirements for any aftercare for a Non-Therapeutic Male Circumcisions (NTMC), including but not limited to dressing the wound, analgesia and/or worsening care advice.
6
ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 23 February 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
8
COPIES AND PUBLICATION COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. [REDACTED], father 2. [REDACTED], mother 3. [REDACTED], Maternal grandmother 4. [REDACTED] ,uncle 5. [REDACTED] 6. [REDACTED] 7. [REDACTED] 8. [REDACTED] 9. London Ambulance Service (LAS) 10. Department of Health and Social Care (DHSC) 11. Ministry of Housing, Communities and Local Government (MHCLG) I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.
Date of report: 20/02/26 Ref: 2026-0234 Deceased name: Sean Williams Coroners name: Mary Hassell Coroners Area: Inner North London This report is being sent to:...
Date of report: 23/4/26 Ref: 2026-0225 Deceased name: Thomas Mayhew Coroners name: Laura Bradford Coroners Area: East Sussex This report is being sent to: Department...
Date of report: 6/3/26 Ref: 2026-0132 Deceased name: Kay Wilson Coroners name: Jeremy Chipperfield Coroners Area: County Durham and Darlington This report is being sent...
Date of report: 24/4/26 Ref: 2026-0226 Deceased name: Ellie Herron Coroners name: Paul Marks Coroners Area: Hull and East Riding This report is being sent...
Date of report: 15/4/26 Ref: 2026-0222 Deceased name: David Roomes Coroners name: Ian Potter Coroners Area: Kent and Medway This report is being sent to:...
Date of report: 20/4/26 Ref: 2026-0223 Deceased name: Paul Hutchinson Coroners name: Richard Furniss Coroners Area: West London This report is being sent to: Local...
