The button battery was likely to have come a remote control: Button batteries once ingested can lead to catastrophic consequences for a child: are used with increasing frequency in every day household devices which are often easily accessible by children: The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children's toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children: NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved: The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work had taken place: day from July The from They

3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally: The Hospital's POAU did not follow their system on 6th July and the Doctor on 6"h July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death: There was not at the time an audit system in place to ensure that systems in the POAU were being complied with It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
5. The importance of carrying out a full assessment ofa child or documenting fully why it was not carried out on 6"h was not recognised by the medical staff involved_ NWAS staff partly based decision making on 9"h July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service.