A coroner has warned that more babies could die from infected circumcisions in the UK after the death of a six-month-old boy exposed a lack of infection control training and accreditation for circumcisers.

Mohamed Abdisamad died in February 2023 of a streptococcus infection. He had a cardiorespiratory arrest on his way to hospital a week after undergoing a non-therapeutic circumcision, an inquest at west London coroner’s court found in October.

In a prevention of future deaths report published this week, the assistant coroner Anton van Dellen urged the government to take action to avoid similar tragedies.

He 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.”

Mohamed was circumcised at 3pm on 12 February, by an individual who was recommended to his parents, the coroner’s report said. After the procedure, the wound appeared to be healing well, the inquest heard.

But three or four days later he began showing symptoms of illness. When Mohamed’s health became worse on 19 February he was taken to Hillingdon hospital in an ambulance. In the ambulance he had a cardiorespiratory arrest and was pronounced dead later that day.

In his report, Van Dellen expressed concern that any individual without training or continued professional development could conduct non-therapeutic circumcisions. He said he was also concerned that there was no system of accreditation or registrations for those who conduct circumcisions.

Van Dellen noted his alarm that during circumcision rituals there was no requirement for infection control. And there was no duty of aftercare “including but not limited to dressing the wound, analgesia and/or worsening care advice”.

He also highlighted the lack of record keeping by circumcisers, and the absence of any system of consent before circumcision.

A jury inquest, which concluded on 8 October last year, found the medical cause of death to be an “invasive streptococcus pyogenes infection following male circumcision”.

Van Dellen’s report has been sent to the Department of Health and Social Care, and to the Ministry of Housing, Communities and Local Government.

They had 56 days to respond, the coroner said.

Copies of the report were also being sent to Mohamed’s mother and father, his maternal grandmother, his uncle and the London ambulance service.

• This article was amended on 2 January 2026 to clarify details about the cause of death.