Eliza Bashir
PFD Report
Partially Responded
Ref: 2014-0461
Coroner's Concerns (AI summary)
Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.
View full coroner's concerns
1. Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require a lockable battery compartment, notwithstanding compliance with safety regulations.
2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.
3. Oldham Council in collaboration with ROSPA, the Department of Business Innovation and skills and the National Trading Standards Board have initiated a local poster campaign. Following the reporting of this case both locally and nationally, a communications have been received from both Central Manchester University Hospitals NHS Trust and from , Director of the Queensland Injury Surveillance Unit has helpfully provided a link to the following site which she developed to raise awareness again both locally and nationally in Australia.http ://www.gisu.org.au/modcorefrontend/upload/Disc-Batteries QISU.pdf
4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved.
2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.
3. Oldham Council in collaboration with ROSPA, the Department of Business Innovation and skills and the National Trading Standards Board have initiated a local poster campaign. Following the reporting of this case both locally and nationally, a communications have been received from both Central Manchester University Hospitals NHS Trust and from , Director of the Queensland Injury Surveillance Unit has helpfully provided a link to the following site which she developed to raise awareness again both locally and nationally in Australia.http ://www.gisu.org.au/modcorefrontend/upload/Disc-Batteries QISU.pdf
4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved.
Responses
Action Planned
The Department of Health will share information on button battery risks with health visitors, school nurses, and child health leads at Public Health England's regional centers and will contact the National Social Partnership Forum to raise awareness of the issues. (AI summary)
The Department of Health will share information on button battery risks with health visitors, school nurses, and child health leads at Public Health England's regional centers and will contact the National Social Partnership Forum to raise awareness of the issues. (AI summary)
View full response
From Jane Ellison MP Parliamentary Under Secretary of State for Public Health Department of Health Richmond House 79 Whitehall London SWIA 2NS Mr $ Nelson Tel: 020 7210 4850 Senior Coroner HM Coroner' s Court The Phoenix Centre 2 Q JAN 201s LICpl Stephen Shaw MC Heywood OL1O ILR De Mr Nelon _ Thank you for your letter following the inquest into the sad death of Eliza Bashir: Eliza suffered an accidental death as a result of ingesting a button battery which had come from a torch that she had been playing with whilst at home. Damage to her oesophageal wall, which led to her death; was caused by either pressure from the battery, electrical discharge from the battery, or leakage of alkaline material Or heavy metals from the battery core. Tunderstand the button battery was removed by rigid endoscopy performed at the Royal Manchester Children's Hospital and Eliza was discharged home and remained well over the next five Unfortunately, she then collapsed and suffered a cardiac arrest, She was taken to Accident & Emergency Department of the Royal Oldham Hospital but extensive resuscitation could not prevent her death; You raise the following concerns for our attention: Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require lockable battery compartment; notwithstanding compliance with safety regulations: The Consultant Paediatric Surgeon at the inquest said in evidence that both he and his colleagues were unsure how best to deal with incidents such as this. Whilst awareness of the risks and complications arising from ingested button Way days:
batteries was being raised locally, there was a need for the profile of those risks to be raised nationally: Such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to access to them whilst unobserved. Although your concern relating to the display and placement of button batteries in retail outlets is matter for the retailers concerned, my officials have however; shared a copy of your report with colleagues in the Department of Business, Innovation and Skills (BIS) I expect them to liaise with the Royal Society for the Prevention of Accidents (RoSPA) and the National Trading Standards Board (NTSB) to explore a way to address this concern with retailers. Regarding your concern that awareness of the dangers ofbutton batteries be raised nationally, my officials have discussed this case with BIS. BIS have informed us of several awareness campaigns that are being run on both a national and international level. The NTSB developed a national poster safety campaign on behalf of BIS. The campaign was promoted across England and Wales and colleagues in Scotland and Northern Ireland are now also becoming involved. Over 100,000 posters were distributed through sure start centres and nurseries In addition, BIS supports the home safety campaign, concerning button batteries, which is run by RoSPA further details can be found at: http:ILwwwrospa com/homesafetyladviceandinformation/productlbutton-cell batteries aspx On an international level, the Organization for Economic Co-operation and Development (OECD) launched an International Awareness Week on Button Batteries in June 2014 to raise awareness worldwide of the risks and dangers posed by this product; This initiative was aimed at consumers, relevant authorities and stakcholders worldwide, to encourage them to take steps necessary steps to reduce the risk of injuries and deaths 'due to button batteries. Throughout the week, participants CO- ordinated media, social media, online and.on-site initiatives. Details of media releases and online content links are attached. More information on the awareness week can be found at the following link: gain
Department of Health http:ILwww oecdorg/sciencelbutton-battery-safety-awareness_ htm In addition, the European Commission addressed similar issues by hosting a press event on button batteries in Brussels on 17 June 2014 the 2014 International Product Safety Week: Further to this, the of Emergency Medicine in the UK has also issued awareness guidance on button batteries on its website, linked to an on the National Poisons Information Service and the National Capital Poisons Center in America. This provides emergency advice for those who have swallowed a button battery and for those clinicians presented with a potential button battery case. There are some scientific developments in the area of button battery safety and research continues into producing button batteries with special coatings that stops them causing harm if are swallowed. I share your concerns about the dangers ofbutton batteries and hope that the above examples help to reassure you that awareness of these dangers is raised at both a national and international level. However; I will ensure that the information in your letter and this reply is shared with health visitors, school nurses and the child health leads at Public Health England s regional centres s0 that awareness of the risks ofbutton batteries is further raised. My officials will give consideration as to how these professionals can best be supported to use this information to make parents and child carers aware of this issue. In addition, my officials will contact the membership of the National Social Partnership Forum, which includes NHS trade unions and employers, to raise awareness of the issues concerning button batteries as outlined in your report: 1 hope that this response is helpful and am grateful to you for bringing the circumstances of Eliza'$ death to my attention: Kinud JANE ELLISON week during College item they being ~Jad _
batteries was being raised locally, there was a need for the profile of those risks to be raised nationally: Such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to access to them whilst unobserved. Although your concern relating to the display and placement of button batteries in retail outlets is matter for the retailers concerned, my officials have however; shared a copy of your report with colleagues in the Department of Business, Innovation and Skills (BIS) I expect them to liaise with the Royal Society for the Prevention of Accidents (RoSPA) and the National Trading Standards Board (NTSB) to explore a way to address this concern with retailers. Regarding your concern that awareness of the dangers ofbutton batteries be raised nationally, my officials have discussed this case with BIS. BIS have informed us of several awareness campaigns that are being run on both a national and international level. The NTSB developed a national poster safety campaign on behalf of BIS. The campaign was promoted across England and Wales and colleagues in Scotland and Northern Ireland are now also becoming involved. Over 100,000 posters were distributed through sure start centres and nurseries In addition, BIS supports the home safety campaign, concerning button batteries, which is run by RoSPA further details can be found at: http:ILwwwrospa com/homesafetyladviceandinformation/productlbutton-cell batteries aspx On an international level, the Organization for Economic Co-operation and Development (OECD) launched an International Awareness Week on Button Batteries in June 2014 to raise awareness worldwide of the risks and dangers posed by this product; This initiative was aimed at consumers, relevant authorities and stakcholders worldwide, to encourage them to take steps necessary steps to reduce the risk of injuries and deaths 'due to button batteries. Throughout the week, participants CO- ordinated media, social media, online and.on-site initiatives. Details of media releases and online content links are attached. More information on the awareness week can be found at the following link: gain
Department of Health http:ILwww oecdorg/sciencelbutton-battery-safety-awareness_ htm In addition, the European Commission addressed similar issues by hosting a press event on button batteries in Brussels on 17 June 2014 the 2014 International Product Safety Week: Further to this, the of Emergency Medicine in the UK has also issued awareness guidance on button batteries on its website, linked to an on the National Poisons Information Service and the National Capital Poisons Center in America. This provides emergency advice for those who have swallowed a button battery and for those clinicians presented with a potential button battery case. There are some scientific developments in the area of button battery safety and research continues into producing button batteries with special coatings that stops them causing harm if are swallowed. I share your concerns about the dangers ofbutton batteries and hope that the above examples help to reassure you that awareness of these dangers is raised at both a national and international level. However; I will ensure that the information in your letter and this reply is shared with health visitors, school nurses and the child health leads at Public Health England s regional centres s0 that awareness of the risks ofbutton batteries is further raised. My officials will give consideration as to how these professionals can best be supported to use this information to make parents and child carers aware of this issue. In addition, my officials will contact the membership of the National Social Partnership Forum, which includes NHS trade unions and employers, to raise awareness of the issues concerning button batteries as outlined in your report: 1 hope that this response is helpful and am grateful to you for bringing the circumstances of Eliza'$ death to my attention: Kinud JANE ELLISON week during College item they being ~Jad _
Sent To
- Central Manchester University Hospitals NHS Foundation Trust
- Department of Health and Social Care
- Oldham Metropolitan Borough Council
Response Status
Linked responses
1 of 3
56-Day Deadline
19 Dec 2014
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 5 th April 2013 I commenced an investigation into the death of Eliza Bashir (aged 1 year) for whom the cause of death was given as being that of la) Fatal Exsanguination due to Perforated Retro-Oesophageal Right Subclavian Artery, ib) Perforated Oesophagus, ic) Ingested button battery and at an Inquest held at the Rochdale Coroners Court Heywood on the 7 th October 2014, the conclusion of an ‘Accidental Death’ was made.
Circumstances of the Death
On the evening of the 22’ March 2013 Eliza was playing with her siblings in their parents bedroom. A torch with which they were playing broke and Eliza swallowed one of the button batteries that came from the torch. Parents initially assumed that the battery would be expelled naturally but the family were subsequently advised to take Eliza to the local Accident & Emergency Department where x-rays revealed that the battery was stuck in the oesophagus. She was transferred to the Royal Manchester Childrens Hospital where on the 24 March 2013 the battery was removed by rigid endoscopy. Eliza was discharged home on the morning of the 25 th March 2013 and remained well over the next five days. On the morning of the 30 th March 2013 she collapsed and by the time of her arrival at the Accident & Emergency Department of the Royal Oldham Hospital she was in cardiac arrest. Extensive resuscitation failed to avert death. Eliza’s case was unusual in that the battery was removed quite quickly after swallowing and she was quite well for almost a week before her final collapse. Additionally, Eliza had an aberrant right subclavian artery which lay just behind the oesophagus. Damage to the oesophageal wall was caused either by a) Damage due to pressure from the battery, or b) Electrical discharge from the battery, or c)__Leakage_of_alkaline_material_or_heavy_metals from the_battery_core
Copies Sent To
1. Central Manchester University Hospitals NHS Foundation Trust
2. Department of Health
3. Oldham Metropolitan Borough Council Trading Standards Department
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.