Yusuf’s family has called for a full inquest and insisted that the NHS learn lessons from his death.
His mother, Soniya Ahmed, said: “Every night when I close my eyes I hear Yusuf’s helpless voice in my ears saying, ‘Mummy, I can’t breathe, I can’t breathe, I really can’t’.
“And the image of him being handed over to me after his life ended, as though someone has torn my heart out and placed it in my hands.”
She said her son was “left to die right beside me”.
“He was crying in pain yet he received no pain relief.
“They say a mother’s instinct is a powerful thing, it can neither be ignored nor explained, yet my concerns were ignored each and every time.”
Ms Ahmed described the failings in his care as “truly shocking”, citing 13 opportunities the report outlined to escalate her son’s care.
“Yusuf deserved better, every child does. I will never stop speaking his name. I will never stop fighting for him. We demand accountability, we demand change,” she added.