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Call for more guidance on how to deal with potentially fatal button battery cases

Health professionals ‘need better decision-making tools’ related to swallowed batteries

Health professionals ‘need better decision-making tools’ related to swallowed batteries


Picture: Andrew Matthews/PA Wire

Health professionals need better guidance on spotting potentially fatal signs when children swallow button batteries, a health safety body says.

The Healthcare Safety Investigation Branch (HSIB) highlighted the death of a three-year-old girl who swallowed a 23mm battery.

Button or coin cell batteries – commonly found in toys, remote controls and car fobs – can become lodged in the oesophagus, where a chemical reaction occurs that erodes tissue.

Efforts to obtain treatment

A report by the HSIB details efforts by the parents of the girl over several days in 2017 to obtain treatment after she was initially diagnosed with tonsillitis and prescribed antibiotics.


RCN’s Helen Donovan urges
parents to be vigilant.

Further visits to the family GP and a local hospital followed, resulting in more antibiotics being dispensed. Three days later, following a second call that day to 999, the girl died after she was taken by ambulance to hospital.

The HSIB, which conducts independent investigations of patient safety concerns in NHS-funded care across England, identified a lack of national guidance to support decision-making for health professionals regarding the batteries.

Metal detectors

It recommended that the Royal College of Paediatrics and Child Health work with the Royal College of Emergency Medicine to enhance existing decision-making tools.

It also suggested a study be carried out evaluating the use of handheld metal detectors as a non-invasive way to scan children presenting with non-specific symptoms.

HSIB chief investigator Keith Conradi said: ‘We are not just putting the onus on public safety awareness but also looking at what can be done before products reach homes and what clinical staff need to be aware of to make the right diagnosis.

‘As we’ve seen in our reference case, the consequences of a child swallowing a button-coin cell battery can be devastating.’

Safe retailing

The HSIB also recommended a government strategy to improve button and coin cell battery safety, including a standard covering their design, product casing, packaging and safe retailing practices.

Public awareness of the potential dangers of such batteries – particularly for children, who are more likely to put things in their mouths – needs to be increased, it said.

RCN professional lead for public health Helen Donovan welcomed the report and urged parents to be vigilant. She said: ‘Education on the risks of leaving children and young people alone where they could accidentally access these batteries can also help in preventing accidents.’


Further information

Read the report: Investigation into undetected button/coin cell battery ingestion in children

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