This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown and undetected ingestion of a button battery. 

Please note that this investigation has previously been known as 'Button battery ingestion' and 'Undetected button battery ingestion in children'.

Investigation summary

The national investigation focused on: 

  • Reviewing the current processes for the identification and treatment of button/coin cell battery ingestion in children under the age of five years, including the management of associated non-specific symptoms when ingestion is unknown.
  • Reviewing communication and information sharing between NHS 111, primary care services, out-of-hours, acute and ambulance services.
  • Reviewing how ambulance services assess and manage paediatric cases in relation to non-specific symptoms.

Download and read the full report.

Safety recommendations

We've made safety recommendations to the Department for Business, Energy and Industrial Strategy, the Royal College of Paediatrics and Child Health, the Royal College of Emergency Medicine, the Association of Ambulance Chief Executives and the College of Paramedics as a result of this investigation.

We expect these organisations to respond to their recommendations within 90 days of the publication of the investigation report. Their responses will be published here when they’re available.

Department for Business, Energy and Industrial Strategy

Recommendation 2019/034

It is recommended that the Department for Business, Energy and Industrial Strategy develops a strategy to improve button/coin cell battery safety, to include producing a fast-track standard covering/considering battery design, product casing, packaging and safe retailing practices.

Recommendation 2019/038

It is recommended that the Department for Business, Energy and Industrial Strategy highlights to the general public the dangers of button/coin cell batteries.

Royal College of Paediatrics and Child Health and Royal College of Emergency Medicine

Recommendation 2019/035 

It is recommended that the Royal College of Paediatrics and Child Health develop a key practice point within a decision support tool for suspected or known ingestion of button/coin cell batteries, and to be supported in this development by the Royal College of Emergency Medicine.

Association of Ambulance Chief Executives

Recommendation 2019/036

It is recommended that the Association of Ambulance Chief Executives agrees guidance that can inform its members on the competency and authority for staff to convey, refer and discharge children under five years who are subject to 999 calls.

College of Paramedics

Recommendation 2019/037

It is recommended that the College of Paramedics develops supervision guidance for paramedics, applicable to all relevant practice settings.

Safety observations

Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.

This investigation makes the following safety observations:

  1. There is limited connectivity and interoperability across healthcare information technology systems. This can impact on the availability and quality of information regarding patients’ clinical history, previous contact with healthcare professionals or services and past interventions.
  2. It would be beneficial for a review to be undertaken of the content of the Advanced Paediatric Life Support course, and any similar courses hosted by other providers, to ensure that the management and issues associated with the ingestion of button/coin cell batteries is strengthened as required in response to this report.
  3. It may be beneficial for 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 years.
  4. There appear to be opportunities to reduce the variation in provision of and access to clinical leadership in the ambulance sector, when compared with the general management structure.
  5. The provision of protected time for paramedics and other grades of patient-facing ambulance staff to undertake supervision and clinical updates is limited. This may impact upon the maintenance of staff competency and may limit trusts’ ability to disseminate learning opportunities.
  6. Information could be collected by a surveillance study of all children attending emergency departments with button/coin cell battery ingestion, to better understand incidence and outcomes.

Find out more by reading our report launch news story.