In March 2018, a national investigation was triggered by the Healthcare Safety Investigation Branch (HSIB) into the dangers of button battery ingestion after the tragic case of a three-year-old child who died.

Here, Professor Derek Burke, Head of Clinical Governance at Gibraltar Health Authority, GMC suitable person and formerly medical director and consultant in paediatric emergency medicine at Sheffield Children’s NHS FT, discusses the issue, and his role as a subject matter adviser to HSIB in its national investigation into it.

The ingestion of any foreign object by a child can be dangerous. Following the tragic loss of a child in 2017 to the unwitnessed ingestion of a button battery, the HSIB has conducted a national investigation to determine what learnings can be taken from this event.

Focusing on a three-year-old who had ingested a 23mm coin cell battery, the investigation revealed that in the space of nine days, the child in question had seven contacts with different healthcare and hospital services in the community. Reporting non-specific symptoms including upper abdominal pain, vomiting, an inability to swallow and take food and a raised temperature, a diagnosis of tonsillitis was made and antibiotics prescribed, with no suspicion a foreign object had been ingested. Following the continuation of symptoms and ongoing parental concern over a nine-day period, the child was admitted to hospital in a state of cardiac arrest secondary to a massive haemorrhage but died shortly after admission.

A post-mortem examination was carried out, finding a coin cell battery (subsequently found to be missing from a remote control), lodged in the child’s oesophagus resulting in the erosion of the oesophageal wall and the formation of an oesophageal arterial fistula.

In April 2018 the HSIB identified several safety issues in the initial review that fed back into the ongoing investigation. These included:

• the current processes for the identification and treatment of button battery ingestion in children under the age of five years, including the management of associated non-specific symptoms when ingestion is unknown,

• the communication and information sharing processes between NHS111, primary care services, out of hours services, acute and ambulance services,

• and how ambulance services assess and manage paediatric cases in relation to non-specific symptoms.

Another example: Freya’s story

The following is a case study and account from a father of a child who survived the ingestion of a button battery. The case was not investigated by the HSIB but is shared by the family to raise awareness of the dangers of button battery ingestion.

Freya, a one-year old girl, was taken to hospital by her parents when she began to choke. An x-ray revealed a button battery, subsequently confirmed to be a Lithium Ion Battery lodged in the oesophagus when removed at operation. There was a chemical burn to the oesophagus but no perforation. It was estimated that the battery had been in the oesophagus for three weeks. In the weeks preceding the visit to hospital Freya had been seen several times by her GP with wheezy breathing and had been diagnosed with asthma or croup. A subsequent search of the house revealed that Freya had probably opened the rear battery casing of a set of bathroom scales and swallowed the battery that had fallen out. Other than high blood levels of Manganese for several weeks Freya made a rapid and full recovery. Freya’s parents have raised a petition to 10 Downing Street to have child-safe fastenings to any product containing lithium batteries, including children’s toys, and to consider a ‘quantum-coating’ on batteries.

Applying the learnings from a national investigation

Following an extensive investigation, and engaging with key stakeholders, including safety and industry experts, the HSIB have produced the following safety message:

A lodged button battery in a child under the age of 5 years has the potential to cause very serious harm.

Button batteries are designed for use in a wide variety of small household appliances and toys. The Toys (Safety) Regulations 2011 mandates that in toys the battery casing is secured in such a way that young children will be unable to access the battery however, the same is not true for the household products which may therefore be opened by children and the battery ingested. Lithium button batteries are most dangerous as they are more powerful. Larger batteries of 20 mm diameter or more are most likely to become lodged in the smaller diameter of oesophagus in younger children. Older children and adults are at lower risk as, if ingested, the battery will generally pass through the body without causing harm.

Button batteries lodged in the oesophagus may cause severe tissue damage in as little as 2 hours, with delayed complications such as oesophageal perforation and exsanguination after fistulisation into a major blood vessel etc., which may and has led to death.

Unwitnessed ingestion is particularly challenging to diagnose, as a child may present with non-specific symptoms such as upper abdominal pain, a burning sensation in the chest, vomiting and not eating (amongst others). If this is the case, the advice would be to investigate further to exclude the ingestion of a button battery or other foreign body.

The HSIB ‘Undetected button battery ingestion in children’ investigation report is now available. The report includes safety recommendations to national bodies to improve patient safety in this area.

What is the Healthcare Safety Investigation Branch (HSIB)?

The Healthcare Safety Investigation Branch conducts independent investigations of patient safety concerns in NHS-funded care across England. Founded on 1 April 2017, its purpose is to improve patient safety through effective investigations that do not apportion blame or liability. The HSIB also provides recommendations to improve healthcare systems and processes to reduce risk and improve safety. Although funded by the Department of Health and Social Care (DHSC) and hosted by NHS Improvement, it acts independently. It is also independent from any NHS organisations and the Care Quality Commission (CQC).

National investigations

The HSIB’s national investigations can encompass any patient safety concern that occurred in NHS-funded care in England after 1 April 2017. The HSIB decides what to investigate based on the scale of risk and harm, the impact on individuals involved and on public confidence in the healthcare system, as well as the potential for learning to prevent future harm.

For further information and resources, including published investigation reports, please visit the HSIB website.