The British Association of Paediatric Surgeons

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First report 9 Feb 2024•Latest report 9 Feb 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
6

Described in responses

Concerns and recipient responses

Statements from The British Association of Paediatric Surgeons linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. 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. The report was sent to The British Association of Paediatric Surgeons; that does not assign responsibility.

    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. ”
    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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026