Eliza Bashir · Prevention of Future Deaths report

On the 5th April 2013 I commenced an investigation into the death of Eliza Bashir (aged 1 year) for whom the cause of death was given as being that of 1a) Fatal Exsanguination due to Perforated Retro-Oesophageal Right Subclavian Artery, 1b) Perforated Oesophagus, 1c) Ingested button battery and at an Inquest held at the Rochdale Coroners Court Heywood on the 7th October 2014, the conclusion of an ‘Accidental Death’ was made.

On the evening of the 22nd March 2013 Eliza was playing with her siblings in their parents bedroom. A torch with which they were playing broke and Eliza swallowed one of the button batteries that came from the torch. Parents initially assumed that the battery would be expelled naturally but the family were subsequently advised to take Eliza to the local Accident & Emergency Department where x-rays revealed that the battery was stuck in the oesophagus. She was transferred to the Royal Manchester Childrens Hospital where on the 24th March 2013 the battery was removed by rigid endoscopy. Eliza was discharged home on the morning of the 25th March 2013 and remained well over the next five days. On the morning of the 30th March 2013 she collapsed and by the time of her arrival at the Accident & Emergency Department of the Royal Oldham Hospital she was in cardiac arrest. Extensive resuscitation failed to avert death.

Eliza’s case was unusual in that the battery was removed quite quickly after swallowing and she was quite well for almost a week before her final collapse. Additionally, Eliza had an aberrant right subclavian artery which lay just behind the oesophagus.

Damage to the oesophageal wall was caused either by :-

a) Damage due to pressure from the battery, or

b) Electrical discharge from the battery, or

c) Leakage of alkaline material or heavy metals from the battery core

1. Evidence from the Trading Standards Officer confirmed that because the torch was not classified as a toy, it did not require a lockable battery compartment, notwithstanding compliance with safety regulations.

2. Consultant Paediatric Surgeon frankly asserted that both he and his colleagues were still worried as they did not know how best to deal with incidents such as this and whilst awareness of the risks and complications arising from ingested button batteries were being raised locally, there was a need for the profile of those risks to be raised nationally.

3. Oldham Council in collaboration with ROSPA, the Department of Business Innovation and skills and the National Trading Standards Board have initiated a local poster campaign. Following the reporting of this case both locally and nationally, a communications have been received from both Central Manchester University Hospitals NHS Trust and from ████████, Director of the Queensland Injury Surveillance Unit has helpfully provided a link to the following site which she developed to raise awareness again both locally and nationally in Australia.http://www.qisu.org.au/modcorefrontend/upload/Disc-Batteries-QISU.pdf

4. Concern remains that such batteries are sold in supermarkets and other retail establishments and are often on display at a level that would enable small children to gain access to them whilst unobserved.