Dear Coroner Hassell, RCR Response to Regulation 28: Prevention of Future Deaths report issued on 9 February 2024 in relation to the death of Kazarie T’Calla Kwaku Dwaah-Lyder I was very sorry to read about the death of Kazarie and I would firstly like to express my sincerest condolences to Kazarie’s family for the very sad and tragic loss of their child. We take the matters raised in your report very seriously and are committed to learning from cases where there have been bad outcomes. We have been specifically asked to consider whether national guidance could be developed for children suspected of swallowing a non-radio opaque object whose symptoms persist. This question was discussed in detail with senior colleagues at the Royal College of Paediatrics and Child Health, British Association of Paediatric Surgeons and the British Society of Paediatric Radiology. I note the response from the Royal College of Paediatrics and Child Health to your report which details the conclusions of these discussions and the RCR would endorse this response. As noted in the RCPCH response, there is an existing multi-professional clinical working group, currently chaired by the British Association of Paediatric Surgeons, looking to develop guidance to prevent fatalities caused by children swallowing button batteries. This multi- professional group has agreed to consider whether guidance on swallowing non-radio opaque objects could also be developed as part of that scope of work and I can now confirm that a paediatric radiologist has been appointed to this group to contribute to this important work. The RCR cannot comment on individual cases, however, my understanding is that the circumstances surrounding Kazarie’s death are tragic and extremely rare. The development of national guidance in this area is complex. Any potential guidance in light of this case will also need to carefully consider the significant risks and potential harm posed to a large proportion of young children from (potentially unnecessary) investigations which involve general anaesthesia and exposing children to significant ionising radiation. Decisions about

paediatric imaging need to take into account the increased risk from ionising radiation in children from factors such as cumulative radiation risk over a lifetime, longer lifetime to express relative risk, and that a growing child has more radiosensitive tissues. I note these points will be considered by the clinical working group based on the best interests of children and young people. The RCR has also highlighted your report with the British Society of Paediatric Radiology, a special interest group for radiologists in the UK and Republic of Ireland who practise paediatric radiology, to raise awareness of the circumstances surrounding Kazarie’s death for future learning amongst the paediatric radiology community. I am grateful to you for bringing these matters of concern to our attention and for giving us the opportunity to respond.

Dear Coroner Hassell 

British Association of Paediatric Surgeon is (BAPS) Response to the Inquest Touching the Death of Kazarie T’Calla Kwaku DWAAH-LYDER A Regulation 28 Report – Action to Prevent Future Deaths

Thank you for sharing your report with us regarding the tragic and untimely passing of Kazarie Dwaah-Lyder.

Senior colleagues in  the British Association of Paediatric Surgeons (BAPS) and RCPCH and RCR have discussed the report together

We were again saddened to hear of another fatal case following a Foreign Body Ingestion (FBI) in a child. The detailed circumstances surrounding Kazarie’s death will be a matter of further interest as many professionals may be involved in children with FBI.

We fully recognise the wider public interest in such cases. We do not however comment on individual cases or specific inquests.  We have already responded to a request for information from the evening standard and we explained that we will be working widely with the royal colleges and other groups to address the prevention of future deaths.

The BAPS response is below:

National guidance on all types of hazardous foreign body is not currently available. However. BAPS is currently leading a multi professional working group on a pathway for ingestion of button batteries. Obviously we cannot be specific about all types of FBI but we feel this group might consider a generic pathway for all FBI in children. With more specific guidance for the commonly reported hazardous FBs and including those that may be minimally or non radio opaque (radiolucent) on plain X-ray . 

They have advised that they would be happy to receive your report and consider whether guidance could be developed as part of that scope of work. The group includes clinicians working in emergency medicine, gastroenterology with endoscopy expertise, Paediatric and ENT surgeons in association with NHS commissioners. The working group would be pleased to invite a paediatric radiologist representing the British Society of Paediatric radiologists (BSPR) with the RCR to consider aspects of the pathway relating to detection of FBI through imaging. The British Association of Paediatric Otorhinolaryngologists (BAPO) are well positioned to give advice on endoscopy of the pharynx and airway and I will share this with them. 

It is our sincere hope that we wil be able to offer an accessible and timely care pathway for all children suspected of FBI. We understand that these points will be considered by the working group based on the best interests of children and young people. The wider problem is complex 

Four phases of a pathway needs consideration 1 Prevention 2 Presentation/escalation or activation of emergency teams 2 Detection by imaging and or endoscopy 3 Intervention & extraction 4 Identification and treatment of complications or after effects 

Regarding prevention BAPS have previously partnered with the child accident prevention trust in 2021 in an awareness campaign highlighting the FBI of button batteries and strong magnets

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We all recognise that FBI represents a common problem in children. The history and physical examination are usually not enough to recognise the presence of a FB. Many are unwitnessed, undetected and will pass unnoticed. Children who swallow may be asymptomatic on initial presentation, or present to the emergency services with non-specific findings such as irritability and feeding issues. foreign bodies that become lodged in the oesophagus may result in a wide spectrum of symptoms including vomiting, drooling, choking, chest pain and feeding refusal. Respiratory symptoms (e.g., wheezing, distress, cough) can be present when the object is closer to the airway. Any of these symptoms might also  common in children with upper respiratory tract viral illnesses.

Detection of all non radio opaque  (radiolucent) or low opacity objects will be more challenging. A rational approach to resource utilisation will be important in order to be made to minimise risks of exposure to ionising radiation, general anaesthesia or interventional procedures.

A comprehensive systematic review of publications of radiolucent FBI literature is underway led by a group of paediatric surgeons involved in the case. 

The information within your report and our response will also be shared with the wider collaborating professional groups, and through the BAPS communications and professional meetings. We will share quality improvements and recommendations arising from our subsequent work.

Thank you for seeking our opinions and contributing to our current work. 

We offer our sincere condolences and heartfelt sympathy to Kazarie’s family.

Our intentions as always are to advocate the well-being of children and to prevent an event like this from happening again.

Dear Coroner Hassell

Re: RCPCH response to the Inquest Touching the Death of Kazarie T’Calla Kwaku DWAAH-LYDER. A Regulation 28 Report – Action to Prevent Future Deaths.

Thank you for sharing your report with us regarding the tragic and untimely passing of Kazarie Dwaah-Lyder. We were saddened to read the circumstances surrounding Kazarie’s death and have discussed with senior colleagues within the RCPCH, including the British Association of Paediatric Surgeons and British Society of Paediatric Gastroenterology, Hepatology and Nutrition, and also with the Royal College of Radiologists.

Whilst we cannot comment on the specific details around Kazarie’s passing, we have read your report carefully and would like to offer a response to your concerns, and other areas where the Royal College of Paediatrics and Child Health will bear most impact.

Your report asked whether national guidance could be developed for children suspected of swallowing a non radio opaque object whose symptoms persist. Having gathered views from senior colleagues, I have understood that the circumstances surrounding Kazarie’s death are tragic and exceptionally rare.

I understand from the British Association of Paediatric Surgeons that a clinical working group has been set up to look at guidance development for button battery ingestion, and they have advised that they would be happy to receive your report and consider whether guidance could be developed as part of that scope of work. The group includes clinicians working in emergency care, gastroenterology with endoscopy expertise, surgery and other national clinical commissioners. The working group would be pleased to invite a paediatric radiologist to look at this and advise on appropriate outputs as agreed.

I have heard from senior clinicians that in the context of a child who has swallowed a non radio opaque object, there is a balance to be made between arranging for scans (which may likely need a general anaesthetic and could result in a not insignificant dose of ionising radiation), whilst also offering an accessible and timely care pathway for all children suspected of swallowing objects. I understand that these points will be considered by the working group based on the best interests of children and young people.

The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early summer, where further actions may be identified.

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Thank you for seeking our views and reminding us of the importance of this work. Our sincere condolences are with Kazarie’s family.