Recurring concern

Unreliable treatment and observation of ingested foreign bodies

First to latest report 1 Aug 2016 — 19 Jun 2024

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
8

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable treatment and observation of ingested foreign bodies’ and satisfy this evidence boundary: Two distinct reports directly support treatment selection, observation and planning after foreign-body ingestion. The third assertion concerns the broader and materially different act of foreign-object insertion and must be excluded from an ingestion-specific parent.

What is not included
  • Excludes generic mental-health assessment, observation or treatment deficiencies where foreign-body ingestion or insertion is not the material safety condition.
  • Excludes prevention or control of access to objects before ingestion, including custodial contraband or self-harm-item controls, unless the assertion concerns clinical management after ingestion.
  • Excludes failures occurring after an appropriate foreign-body management plan has been established when the remaining issue is unrelated downstream care.
  • Excludes management of unrelated swallowed substances, medication overdoses or food bolus events unless the assertion explicitly concerns the same foreign-body ingestion process.
  • Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support treatment selection, observation and planning after foreign-body ingestion. The third assertion concerns the broader and materially different act of foreign-object insertion and must be excluded from an ingestion-specific parent.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Chloe HUNT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider the complexities of foreign-body removal when selecting endoscopic or surgical treatment

    Wider context from the report

    “a. Imaging established Chloe had swallowed 3 full-sized pens, 2 free in her stomach and 1 was impacted in her duodenum. There was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. Endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite. ”

    Source location

    Chloe HUNT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about care at Colchester General Hospital fall outside NHS England’s remit.

    Verbatim wording from the response

    “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 26 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.

    Verbatim wording from the response

    “Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 26 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Proceeding to endoscopy was clinically indicated and reasonable based on the available information, assessed risks and informed consent.

    Verbatim wording from the response

    “Having reviewed the decision process taken on Monday 14 March 2022, it is noted that the available imaging did not confirm that a pen was impacted, and the clinicians caring for Chloe could only establish that the pen impacted by undertaking an endoscopy. Up to this point, it was the working diagnosis that the pens could all be removed safely under endoscopy.”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 2 · response
    Published 26 June 2024

    Open published response

  2. Inner North London

    AI-generated summary

    Kazarie T’Calla Kwaku DWAAH-LYDER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kazarie died after swallowing a googly eye in February 2022; the foreign body was not detected by x-ray or fluoroscopy, and he later became critically ill and was admitted to hospital in April 2023. The report raised concern about the lack of national guidance on investigating suspected swallowed non-radio-opaque foreign bodies when symptoms persist despite negative x-ray and fluoroscopy.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of national guidance for investigating children with persistent symptoms after suspected ingestion of a non radio opaque object despite negative x-ray and fluoroscopy

    Wider context from the report

    “It was suggested to me in evidence that children suspected of having swallowed a non radio opaque object such as a googly eye, whose symptoms (unlike Kazarie’s) persist, should undergo an endoscopy even if they have had a negative x-ray and fluoroscopy. I was told that there is a lack of national guidance for such a situation. I appreciate that there are multiple considerations in planning investigations, such as the risks associated with CT scanning and the risks associated with the administration of a general anaesthetic. It seems that the matter would benefit from consideration at a national level. ”

    Source location

    Kazarie T’Calla Kwaku DWAAH-LYDER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Lead a multidisciplinary working group developing a button-battery ingestion care pathway.

    Verbatim wording from the response

    “National guidance on all types of hazardous foreign body is not currently available. However. BAPS is currently leading a multi professional working group on a pathway for ingestion of button batteries. Obviously we cannot be specific about all types of FBI but we feel this group might consider a generic pathway for all FBI in children. With more specific guidance for the commonly reported hazardous FBs and including those that may be minimally or non radio opaque (radiolucent) on plain X-ray .”

    Source location

    Response from British Association of Paediatric Surgeons
    Page 1 · response
    Published 21 February 2024

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Tammy Mary Louise WATKINS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of policy for managing suspected foreign-body ingestion medically

    Wider context from the report

    “3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”

    Source location

    Tammy Mary Louise WATKINS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and update the foreign-body ingestion management procedure, including a bespoke care-plan framework for patients at clinical risk.

    Verbatim wording from the response

    “3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain ratification of the revised foreign-body ingestion policy and additions through the Trust Clinical Policies approval group.

    Verbatim wording from the response

    “3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate the ratified foreign-body ingestion policy to all areas where that risk is present.

    Verbatim wording from the response

    “3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake case reviews of subsequent similar presentations to assess whether learning from the death is embedded and sustained.

    Verbatim wording from the response

    “To review current practice and to continue to address areas of concern, Rampton Hospital are undertaking case reviews of subsequent similar presentations to identify if the learning from Tammy’s death has been embedded and sustained. We will ensure that any learning or areas for continued training are identified within these case reviews are responded to and included within Hospital Life Support training/ any future enhanced training that is provided.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 19 January 2024

    Open published response

  4. County Durham and Darlington

    AI-generated summary

    Pamela Gressman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Pamela Gressman died following the ingestion of foreign bodies, one or more of which led to a perforation of the colon; the inquest recorded hospital-acquired pneumonia as the medical cause of death. The report raised concern that insufficient consideration was given to the possible physical effects of the ingested objects and that there was no clear treatment and observation plan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider physical effects of ingested foreign bodies and their link to abdominal pain

    Wider context from the report

    “Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future. ”

    Source location

    Pamela Gressman · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of a clear treatment and observation plan for ingested foreign bodies

    Wider context from the report

    “Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future. ”

    Source location

    Pamela Gressman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the observation and engagement procedure to consider enhanced observations after foreign-object ingestion.

    Verbatim wording from the response

    “• A review of the observation and engagement procedure will include consideration of a period of enhanced observations for a period of time following ingestion of a foreign object to enable close monitoring of any physical side effects but also to monitor if any foreign bodies are passed through stools. Completed”

    Source location

    2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver formal training on delayed physical effects, stool checks, risk and intervention plans, and recording related observations.

    Verbatim wording from the response

    “• Formal training sessions to be delivered to specifically include: ◦ Consideration of the possibility of physical effects (sometimes delayed for days) following swallowing of foreign objects, in particular for patients with known history of this ◦ Clarification of process to check if foreign bodies have been passed in stools by patient ◦ The requirement to have a risk management plan and intervention plan to monitor and manage physical health care symptoms of concern and the need to record related observations (10 case notes to be audited). To be completed 31st October 2016 (delayed due to the challenges of delivering training during the holiday period).”

    Source location

    2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
    Page 2 · response
    Published 1 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with the local Emergency Department to design and share standard work requiring thorax and abdominal X-rays in relevant cases.

    Verbatim wording from the response

    “• Liaison colleagues to work with the local Emergency Department to ensure standard work is designed and shared to ensure X-rays are done of thorax and abdomen in such instances. To be completed by 31st October 2016.”

    Source location

    2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
    Page 2 · response
    Published 1 August 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026