PFD report

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

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Issued 9 Feb 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. 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
    Part of recurring concern: Unreliable treatment and observation of ingested foreign bodies
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

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

    Stated by The British Association of Paediatric SurgeonsStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable treatment and observation of ingested foreign bodies.

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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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Share information and local-improvement suggestions from the report with paediatric members through the patient safety portal.

    Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
  2. 2

    Share information from the report with the Clinical Quality in Practice group for discussion in early summer.

    Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
  3. 3

    Raise awareness of the death’s circumstances within the paediatric radiology community for future learning.

    Stated by Royal College of RadiologistsStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  4. 4

    Share pathway-related endoscopy advice with the British Association of Paediatric Otorhinolaryngologists.

    Stated by The British Association of Paediatric SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
  5. 5

    Conduct a systematic review of literature on radiolucent foreign-body ingestion.

    Stated by The British Association of Paediatric SurgeonsStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
  6. 6

    Run an awareness campaign highlighting the dangers of button batteries and strong magnets.

    Stated by The British Association of Paediatric SurgeonsStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  7. 7

    Share the report and response with collaborating professional groups through communications and professional meetings.

    Stated by The British Association of Paediatric SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
  8. 8

    Share resulting quality improvements and recommendations from subsequent work.

    Stated by The British Association of Paediatric SurgeonsStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Guidance development for button battery ingestion is assigned to a clinical working group established by the British Association of Paediatric Surgeons.

    Stated by Royal College of Paediatrics and Child HealthRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Share information and local-improvement suggestions from the report with paediatric members through the patient safety portal.

Verbatim wording from the response

“The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early summer, where further actions may be identified.”

Source location

Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 21 February 2024

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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

Share information from the report with the Clinical Quality in Practice group for discussion in early summer.

Verbatim wording from the response

“The College will be sharing information and suggestions for local improvement from your report with our paediatric members via its patient safety portal. The information within your report will also be shared for discussion with the RCPCH Clinical Quality in Practice group in early summer, where further actions may be identified.”

Source location

Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 21 February 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

Raise awareness of the death’s circumstances within the paediatric radiology community for future learning.

Verbatim wording from the response

“The RCR has also highlighted your report with the British Society of Paediatric Radiology, a special interest group for radiologists in the UK and Republic of Ireland who practise paediatric radiology, to raise awareness of the circumstances surrounding Kazarie’s death for future learning amongst the paediatric radiology community.”

Source location

Response from The Royal College of Radiologists
Page 2 · response
Published 21 February 2024

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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

Share pathway-related endoscopy advice with the British Association of Paediatric Otorhinolaryngologists.

Verbatim wording from the response

“They have advised that they would be happy to receive your report and consider whether guidance could be developed as part of that scope of work. The group includes clinicians working in emergency medicine, gastroenterology with endoscopy expertise, Paediatric and ENT surgeons in association with NHS commissioners. The working group would be pleased to invite a paediatric radiologist representing the British Society of Paediatric radiologists (BSPR) with the RCR to consider aspects of the pathway relating to detection of FBI through imaging. The British Association of Paediatric Otorhinolaryngologists (BAPO) are well positioned to give advice on endoscopy of the pharynx and airway and I will share this with them.”

Source location

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

Conduct a systematic review of literature on radiolucent foreign-body ingestion.

Verbatim wording from the response

“Detection of all non radio opaque (radiolucent) or low opacity objects will be more challenging. A rational approach to resource utilisation will be important in order to be made to minimise risks of exposure to ionising radiation, general anaesthesia or interventional procedures.”

Source location

Response from British Association of Paediatric Surgeons
Page 2 · response
Published 21 February 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

Run an awareness campaign highlighting the dangers of button batteries and strong magnets.

Verbatim wording from the response

“Regarding prevention BAPS have previously partnered with the child accident prevention trust in 2021 in an awareness campaign highlighting the FBI of button batteries and strong magnets”

Source location

Response from British Association of Paediatric Surgeons
Page 2 · response
Published 21 February 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

Share the report and response with collaborating professional groups through communications and professional meetings.

Verbatim wording from the response

“The information within your report and our response will also be shared with the wider collaborating professional groups, and through the BAPS communications and professional meetings. We will share quality improvements and recommendations arising from our subsequent work.”

Source location

Response from British Association of Paediatric Surgeons
Page 2 · response
Published 21 February 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

Share resulting quality improvements and recommendations from subsequent work.

Verbatim wording from the response

“The information within your report and our response will also be shared with the wider collaborating professional groups, and through the BAPS communications and professional meetings. We will share quality improvements and recommendations arising from our subsequent work.”

Source location

Response from British Association of Paediatric Surgeons
Page 2 · response
Published 21 February 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

Guidance development for button battery ingestion is assigned to a clinical working group established by the British Association of Paediatric Surgeons.

Verbatim wording from the response

“I understand from the British Association of Paediatric Surgeons that a clinical working group has been set up to look at guidance development for button battery ingestion, and they have advised that they would be happy to receive your report and consider whether guidance could be developed as part of that scope of work. The group includes clinicians working in emergency care, gastroenterology with endoscopy expertise, surgery and other national clinical commissioners. The working group would be pleased to invite a paediatric radiologist to look at this and advise on appropriate outputs as agreed.”

Source location

Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 21 February 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026