Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0461, written 24 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2014 |
|---|---|
| Reference | 2014-0461 |
| Deceased | Eliza Bashir |
| Coroner | Simon Nelson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Product related deaths |
| Organisation named | Central Manchester University Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENTTO: 1. Central Manchester University Hospitals NHS Foundation Trust 2. Department of Health 3. Oldham Metropolitan Borough Council Trading Standards Department 4. Family ofthe deceased CORONER I am the Senior Coroner forthe Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, ofthe Coroner’s and Justice Act 2009 and regulations 28 and 29 ofthe Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 5th April 2013 I commenced an investigation into the death of Eliza Bashir (aged 1 year) for whom the cause ofdeath 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 7th October 2014, the conclusion of an ‘Accidental Death’ was made. 4 CIRCUMSTANCES OF DEATH On the evening ofthe 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 ofthe 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 ofthe 2th5 March 2013 and remained well over the next five days. On the morning ofthe 3th0 March 2013 she collapsed and by the time of her arrival at the Accident & Emergency Department ofthe 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 layjust 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_metalsfrom the_battery_core 5 CORONER’S CONCERNS During the course ofthe inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 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 ofthe risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile ofthose 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. Followingthe reporting ofthis case both locally and nationally, a communications have been received from both Central Manchester University Hospitals NHS Trust and from , Director ofthe 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each ofyou respectively, have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days ofthe date ofthis report, namely 1th9 December 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1. Central Manchester University Hospitals NHS Foundation Trust 2. Department of Health 3. Oldham Metropolitan Borough Council Trading Standards Department 4. Family ofthe deceased I am also under a duty to send the Chief Coroner a copy ofyour response. The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy ofthis report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time ofyour response, about the release or the publication ofyour response by the f1’çoroner. Date: 2th4 October 2014 Signed:” 7
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
AE From Jane Ellison MP Parliamentary Under Secretary of State for Public Health Department of Health Richmond House 79 Whitehall London SWI1A 2NS MrS& Nelson Tel: 020 7210 4850 Senior Coroner HM Coroner’s Court 2 The Phoenix Centre 20 JAN 2018 L/Cpl! Stephen Shaw MC Way Heywood OL10 ILR Du My Melion 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. I understand 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 days. 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 a 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 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 gain access to them whilst unobserved. Although your concern relating to the display and placement of button batteries in retail outlets is a 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 of button 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://www.rospa.com/homesafety/adviceandinformation/product/button-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 stakeholders 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: 288 Department | of Health http://www.oecd.org/science/button-battery-safety-awareness-week.htm In addition, the European Commission addressed similar issues by hosting a press event on button batteries in Brussels on 17 June 2014 during the 2014 International Product Safety Week. Further to this, the College of Emergency Medicine in the UK has also issued awareness guidance on button batteries on its website, linked to an item 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 they are swallowed. I share your concerns about the dangers of button batteries and hope that the above examples help to reassure you that awareness of these dangers is being 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 so that awareness of the risks of button 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. I hope that this response is helpful and J am grateful to you for bringing the circumstances of Eliza’s death to my attention. ““ JANE ELLISON
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