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 coin cell 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.

Safety recommendations

We 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.

All organisations responded to their safety recommendations within 90 days of publication of the investigation report.

Department for Business, Energy and Industrial Strategy

Safety recommendation

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.


The Department for Business, Energy and Industrial Strategy (BEIS) welcomes the HSIB’s report. Last year the Government created a new national regulator, the Office for Product Safety and Standards (OPSS), as an office of BEIS, to take the lead in national product safety issues. OPSS is committed to delivering a trusted product safety system giving high levels of protection to consumers.

The PAS [Publicly Available Specification] is part of OPSS’s strategy to provide guidance and support to manufacturers, retailers and other stakeholders on safety considerations for common household items that use button batteries as well as when dealing with the batteries themselves. Whilst there is a legal requirement to ensure that products placed on the market are safe, OPSS recognises that this is an area in which more guidance would be helpful. Button battery safety is regulated under the General Product Safety Regulations, which require that they are safe under normal or reasonably foreseeable conditions of use. Some products, such as toys, are regulated with button battery safety aspects in mind. However, there are no guidelines on what constitutes safety specifically with regards to button battery use for many household items.

For this reason OPSS has commissioned the BSI (British Standards Institution) to produce a PAS for button batteries and household products that use them. A PAS is a fast-track standardisation document that defines good practice standards for a product, service or process. The new PAS will cover the life cycle of button batteries in consumer markets, from purchase to use in household products through to safe disposal. It will provide a guide to best practice for manufacturers and retailers of the batteries and the household products that use them with respect to packaging, product casing, labelling, and disposal to mitigate the risk of ingestion. The PAS recognises the risk that is posed by used batteries left in the house, and also covers the need for immediate safe disposal of used button batteries. The PAS also considers the marketing and packaging of button batteries regarding the security of packaging for each individual battery.

As the PAS sponsor, OPSS has set out the scope for the PAS to ensure that it covers all aspects of safety, including consideration of design, product casing, packaging and retail practices both online and in-store. The scope may be refined further during the PAS development process in response to comments received during Steering Group and public consultations. Membership of the steering group for the PAS include industry, retail, charity and consumer representatives from the Royal Society for Prevention of Accidents (RoSPA), the British Irish Portable Battery Association (BIPBA), the British Retail Consortium (BRC), HSIB, the Child Accident Prevention Trust (CAPT), BSI , the Association of Manufacturers of Domestic Appliances (AMDEA), and techUK which represents the UK tech industry .

The PAS sets the bar in terms of level of quality that can be reached by all actors in the supply chain, with clear guidelines for those who choose to follow it. As a single source of all safety information relating to button batteries and products that use them, the PAS can serve as a resource for enforcement authorities and industry bodies including manufacturers and retailers to consult when determining whether a product meets the GPSR [General Product Safety Regulations] requirement that it is safe. For manufacturers, it will guide consideration of button battery safety in the design of household products that use them, and for retailers it will prompt consideration of safety in the choice of products to stock as well as ensuring that button batteries for sale are placed appropriately and with appropriate warnings, both in shops and online.

The PAS will be fully funded by OPSS to be free to download from the BSI website. This will ensure its widest distribution and use. The indicative timeline for the PAS development is 15 months from initiation to completion, and completion is expected in late 2020. The PAS will undergo review approximately 18 to 24 months following publication, which is BSI’s standard period of review for PAS documents.

Safety recommendation

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


In line with the recommendation made by HSIB, OPSS has commissioned a public awareness campaign to highlight the dangers of button batteries. The campaign materials are targeted towards parents of young children, with the aim of increasing awareness of the risks in this key group. The campaign was launched on 27 June 2019 through GOV.UK, with two main safety charities RoSPA [Royal Society for Prevention of Accidents] and CAPT [the Child Accident Prevention Trust ] also hosting the campaign material and sharing the messages across media platforms to deliver a broader reach. A joint campaign with Netmums was also launched later on 30 August.

When sharing safety messages on button batteries, the OPSS twitter account has used the hashtags #ButtonBatteries which has reached106,989 accounts and #BeBatteryAware which has reached 86,343 accounts by early August 2019. The GOV.UK page has received 627-page views, whilst our leaflets and posters have been downloaded 157 times.

The button battery safety campaign will be revisited before Christmas for the OPSS Toys at Christmas safety campaign. The campaign will also be revisited at regular intervals in the future such as for CAPT’s summer Child Safety Week and holiday times.

These responses were received on 23 September 2019.

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

Safety recommendation

It is recommended that the Royal College of Paediatrics and Child Health (RCPCH) 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.


The RCPCH’s Paediatric Care Online (PCO UK) team are happy to accept safety recommendation 2019/35, made in the report. In July 2019 the team liaised with the Royal College of Emergency Medicine (RCEM) to recruit a content editor, to lead development of this workstream, and expert external peer reviewers from a paediatric emergency medicine background. A content editor was successfully appointed along with five expert external peer reviewers. The team met with the content editor on Friday 16 August to kick-start the work and prepare a first draft of the Key Practice Point (KPP) on button battery ingestion in children.

Going forward further expert external peer reviewers will be recruited from the Association of Paediatric Emergency Medicine (APEM) and British Association of General Paediatrics (BAGP), and consideration made on recruiting a paramedic reviewer.

The estimated timeframe for the first draft of the Key Practice Point is the end of September 2019, whereupon the draft will undergo a series of reviews and a consultation. Publication is planned for early 2020, in conjunction with appropriate communication and dissemination from both RCPCH and RCEM.

This response was received on 5 September 2019.

Association of Ambulance Chief Executives

Safety recommendation

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.


The recommendation was reviewed by the National Ambulance Services Medical Directors group (NASMeD) on the 4th July 2019 and subsequently a working group was established to explore the recommendation and agree on specific actions.

It was felt by the working group that any actions we agree for ambulance services on have implications to the rest of the system, for example to be able to refer children under five years that are not conveyed into primary care. Therefore, the working group lead has been in contact with the Royal College of Emergency Medicine (RCEM), the Royal College of Paediatrics and Child Health (RCPCH), and the College of Paramedics to consider a joint response to the recommendation and to discuss each organisations proposed actions. We are continuing to liaise with them.

We are aware that the RCEM will be helping the RCPCH to develop a Key Practice Point (KPP) within their online decision support tool Paediatric Care Online (PCO UK). We will continue to liaise with them to establish if paramedics will be able to access this on-line tool and how this may guide decisions around the conveyance, referral and discharge decisions of children under five.

We are also awaiting the report of an audit of children under the age of two being undertaken by the RCPCH. This audit was already underway when we received the safety recommendation from yourselves and stems from a letter that all ambulance services received in February 2009 from the RCPCH recommending that all children under the age of 2 are not discharged on scene and are conveyed to hospital. The audit was proposed after discussions at NASMeD around the current variation in conveyance and referral guidance of under 2’s and we have assisted by enabling ambulance care records to be submitted for this audit. We await the report of this audit as we will use it to inform our considerations around your safety recommendation. We anticipate that this audit will help inform future guidance on the conveyance, referral and discharge on scene of children under 2.

We have been in discussion with MPDS and NHS Pathways which are the two systems in use across the English ambulance services to assess 999 calls. We are aware that NHS pathways have now included a question on if a child might have ingested a button battery.

The working group presented three proposed actions to NASMeD on the 4th September. The actions were agreed, and these will be now taken forward.

Action 1

All ambulance Trusts to agree the age at which a child should either be conveyed to an appropriate healthcare facility or referred to a health care professional with more expertise in paediatric assessment and/or at what age a child can be discharged from ambulance service care, with no further follow up arranged by the ambulance service clinicians on scene.

This will be discussed at the NASMeD meeting on the 7th November, and by this time we hope to be able to include the results of the audit of under 2’s.

Action 2

To define the processes and age ranges for referring children that are not conveyed to other Health Care Professionals (HCP) - to include:

Arrange an agreed timeframe for follow up with the accepting HCP and documented by the ambulance health care professional. If discharge on scene is advised, the health care professional to whom the referral is made (with higher urgent and emergency care paediatric expertise than the referring paramedic), has responsibility for that decision.

The point of handover of clinical responsibility, will be when a health care professional to health care professional referral decision has been made and the accepting health care professional in primary care/GPOOH [GP out of hours service]/ED [emergency department]/Paediatric unit have agreed the time and date that they will see the patient or call the parent/guardian to arrange this, or have agreed to discharge on scene.

This will be discussed at the NASMeD meeting on the 7th November

Action 3

To agree a proposal for discussion at Joint Royal Colleges Ambulance Liaison Committee (JRCALC) if a child (agree age) has seen another HCP or other ambulance clinician for the same or a similar presentation/condition in the previous 72 hours they should be conveyed to an emergency department or referred by the assessing ambulance clinician directly to another appropriate HCP.

To be discussed at the next JRCALC meeting on 19th September 2019.

This response was received on 18 September 2019.


As previously stated, the recommendation was reviewed by the National Ambulance Services Medical Directors group (NASMeD) on the 4th July 2019 and subsequently a working group was established to explore the recommendation and agree on specific actions. The actions we agreed were detailed to you in our previous letter.

At the November NASMeD meeting we reviewed the actions and the findings from an audit of patient report forms of children under the age of 2. We had anticipated that the audit would help inform future guidance on the conveyance, referral and discharge on scene of children under 2 but unfortunately this was not the case. The clinical outcome was not explored, and we didn’t think there was sufficient power or granularity in the study to draw any firm conclusions. NASMeD concluded that there is very little evidence available currently to inform us towards agreeing guidance for under 5’s. We are now considering how to gather further evidence and informed opinion to help further discussions on formulation of guidance. We have asked the NHSE/I safety team if they could provide a thematic analysis of SI’s involving children and are awaiting to hear back from them. We are also gathering trust current policies and procedures relating to conveyance, referral and discharge of children.

We are now planning to hold a workshop in the New Year. The workshop will bring together partners to review the available evidence, undertake case review and the objective will be to try and agree guidance as per your recommendation. We have requested that the RCPCH will provide support and expertise at this workshop.

This updated response was received on 24 December 2019.

College of Paramedics

Safety recommendation

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


The report and recommendation have been considered by our Professional Standards Directorate and our Education Directorate. It is our intention to conduct a rapid evidence review to determine what is currently known about clinical supervision, in order that our guidance can be informed by current best evidence related to this subject. We expect this review to be completed by the end of 2019. Our team is working on some draft guidance that we hope to share with key stakeholders for consultation early in 2020. We are also working with the Association of Ambulance Chief Executives, who are producing supervision guidance for ambulance staff. Our intention is that the guidance produced for paramedics in other settings will complement the advice provided for paramedics and other clinicians in ambulance services.

We expect to have prepared a full response to the recommendation by 31 August 2020, with a view to publishing this initial guidance by 30 September 2020. We will then begin a review cycle, considering the content of the guidance on an annual basis.

This response was received on 23 September 2019.

Find out more by reading our report launch news story.