A six month old baby boy died from an infection a week after undergoing a circumcision.
Mohamed Adbidsamed began showing symptoms he was unwell around three to four days following the procedure on February 12, 2023.
He was rushed to Hillingdon Hospital in west London on February 19, according to a recently released ‘Prevention of future deaths’ coroner’s report.
Mohamed went into cardiorespiratory arrest on the same day and was pronounced dead at hospital at 11.55pm.
A jury inquest, which concluded on October 8, 2025, found the medical cause of death to be an ‘invasive streptococcus pyogenes infection following male circumcision’.
The circumciser who carried out the circumcision had been recommended to the parents, the report said.
The report’s author, assistant coroner Anton van Dellen, called for action over what he said was a lack of safety and regulatory measures surrounding non-therapeutic male circumcisions, such as Mohamed’s.
These are circumcisions carried out for non-medical reasons, such as cultural traditions.
In the report, dated December 28, 2025, Dr van Dellen wrote: ‘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.’
He then goes on to list the ‘matters of concern’, which are as follows:
- Any individual may conduct a non-therapeutic male circumcision without any prior training or any Continuing Professional Development (CDP).
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- There is no system of external accreditation and/or registration for individuals who conduct a non-therapeutic male circumcision.
- There is no requirement for any record keeping for individuals who undergo a non-therapeutic male circumcision.
- There is no requirement for any infection control measures for a non-therapeutic male circumcision.
- There are no requirements for any aftercare for a non-therapeutic male circumcision (NTMC), including but not limited to dressing the wound, analgesia and/or worsening care advice.
The coroner also pointed to the lack of a system for obtaining consent prior to the procedure being carried out.
The report is being sent to the Department of Health and Social Care, and to the Ministry of Housing, Communities and Local Government.
They have 56 days from the date of the report being issued to respond, the coroner said.
Copies of the report are also being sent to Mohamed’s mother and father, his maternal grandmother, his uncle, and the London Ambulance Service.
According to the Office of National Statistics, there were 14 deaths in the UK where a circumcision was recorded as a factor between 2004 and 2024.
Of these, seven were boys under the age of 18 and seven were men over the age of 18.
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