The Healthcare Safety Investigation Branch were notified of this case by a senior coroner who issued a Prevention of Future Death report to several bodies (including HSIB) following an inquest. NHS 111, primary care services, out-of-hours, the local hospital and an ambulance trust were all involved in this tragic case.
The parents of a three-year-old child contacted NHS 111 in the early hours of a Friday morning. They were referred to the primary care OOH service which provided telephone advice and the child remained at home. The next morning, a further call was made to NHS 111. They were referred again to the primary care OOH service but seen by a GP this time. They referred the child to the Paediatric Assessment Unit where a specialist registrar prescribed antibiotics. Five days later the family visited their GP as there had been no improvement. Again they were referred to the PAU where further antibiotics were prescribed. Three days later a 999 call was made. Following assessment by two paramedics the child remained at home. Another 999 call was made the same evening. The child was found in cardiac arrest and died on arrival at hospital.
A post mortem revealed a 23mm lithium battery lodged in the child’s oesophagus. The battery had eroded the tissue and caused a fistula between the oesophagus and the aorta leading to a catastrophic haemorrhage.
When HSIB searched the National Reporting and Learning System for incidents in May 2018 alone they found 39 reported patient safety incidents relating to accidental button / coin cell battery ingestion in children from birth to age seven. Given that care is complicated by the fact that battery ingestion is often not witnessed they felt there was learning potential here.
The summary of findings, safety recommendations and observations can be found at pages 50 -51 of HSIB’s report.
The health related recommendations
- Royal College of Paediatrics and Child Health and Royal College of Emergency Medicine to develop a key practice point within a decision support tool for suspected or known ingestion of button / coin cell batteries.
- Association of Ambulance Chief Executives agree guidance that can inform its members on the competency and authority for staff to convey, refer and discharge children under five who are subject to 999 calls.
- College of Paramedics to develop supervision guidance for paramedics applicable to all relevant practice settings.
The safety observations
- Limited connectivity and interoperability across healthcare information technology systems can impact on the availability and quality of information regarding patients’ clinical history, previous contact with healthcare professionals or services.
- Review to be undertaken of the Advanced Paediatric Life Support course to ensure issues related to ingestion of these batteries is strengthened.
- A study to be conducted on the potential for hand held metal detectors to be used as a non-invasive screening tool for non-specific clinical presentations in children under five.
- The provision of protected time for paramedics and other grades of patient facing ambulance staff to undertake supervision and clinical updates is limited.
Other interesting points that the report covers
- The data collected in the Child Death Review Process has never been collated in one place. There are 93 Child Death Overview Panels across the country with each one holding its own records and statistics. There is no national guidance on data retention so there is variation in the amount of data retained.
- Interviews with paramedics revealed a concern that taking a patient history and diagnosis of unwell children were not covered in the training completed by the paramedics attending the incident. HSIB note that not all paramedics are university educated and therefore may not have undertaken any formal training.
Jill Mason, Partner and Head of Health and Care
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