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Embedding safety – reflecting on our button battery investigation

by Helen Jones

As Christmas approaches, Helen Jones National Investigator reflects on HSIB’s button battery investigation and updates on what happened after the high profile report was published.


In December 2018, as Christmas shopping began in earnest, an image of a small red robot appeared on HSIB’s social media with a very important message to share; button batteries pose a deadly risk to children, especially those under five, and can be found in many everyday household items from car key fobs to bathroom scales, in addition to toys.

That public message came just after our interim bulletin was published but while our national investigation into undetected button/coin cell ingestion was ongoing, we felt it was important that we shared the message at a time when people are buying gifts that could contain powerful batteries.

We had launched our investigation following the death of a three-year old girl who had swallowed a 23 mm battery from a remote control and tragically this wasn’t discovered until after she had died. Meeting the child’s family, experiencing first-hand their grief and realising that their previously healthy little girl had been taken from them so abruptly is something that will always stay with me; it was a tragic story that touched everyone’s hearts.

The impact of the December safety campaign carried through to our final report which was published in June 2019. We worked closely with the national organisations we were making safety recommendations to but we also involved and had support from partners that champion child safety like the Child Accident Prevention Trust (CAPT) and those who are crucial in the process before button battery products even reach homes like the British and Irish Portable Battery Association (BAPT).

Our investigation provided the opportunity for all of the key stakeholders with the power to positively influence button/coin cell battery safety to come together in one place and discuss the improvements required collectively.

It was clear as our investigation progressed that we had an opportunity to make recommendations that crossed product safety, public awareness and clinical decision making. The report was published with a lot of media attention and global interest from as far away as Australia, with a focus on how to keep children safe.

Updates four years on

Four years on from that first Christmas message, interest in this investigation has continued with ongoing updates on the impact of our recommendations and new initiatives to enhance button/coin cell safety.

Here are some of the key things that have happened since our publication.

  • Following the HSIB press release in December 2018, the British Retail Consortium alerted manufacturers to the safety warning. This resulted in a manufacturer putting a product on hold, that had an accessible battery compartment, which hadn’t been picked up in the course of checks.
  • The Department of Business, Energy and Industrial Strategy (BEIS) worked collaboratively with key partners to launch a national safety campaign raising awareness of the dangers of button and coin cell batteries. This took place in June 2019 and included a joint campaign with Netmums, with the OPSS hashtag #BeBatteryAware reaching over 80,000 Twitter accounts by early August 2019. Posters and leaflets were also available for download for those not using social media.
  • In consultation with the British Standards Institute (BSI), a target safety strategy was developed which include producing a fast-track standard which considered battery design, product casing, packaging and safe retailing practices. The fast track standard was published on the British Standards Institute website in April 2021 New standard for battery safety | BSI (bsigroup.com). This specifies the safety requirements for new products coming on to the market.
  • As a result of the investigation, NHS111 call handlers now have supporting information on button and coin cell batteries to provide a specific prompt, if questions are being asked about the ingestion of anything harmful and poisonous.
  • In relation to the ambulance services, the following guidance/framework has been introduced to provide additional support to children not conveyed to hospital and those cared for by paramedics being clinically supervised:

- the Association of Ambulance Chief Executives has provided guidance to ambulance trusts relating to children aged 1 to 5 years, who are not conveyed to hospital. This includes a referral and handover of care to another registered healthcare professional, so if a child had swallowed a button/coin cell battery (unwitnessed), there would be ongoing support and hence a safety net.

- a Framework for UK Ambulance Services 2021 has been published to formalise the clinical supervision of paramedics and a further document to cover paramedics in other settings will be published in early 2022.

Each year we will continue to promote the key safety issues, update on developments with any of our implemented recommendations and to enable learning on this issue to continue across the NHS and in the minds of the public.

One of the lasting impressions the parents left was their strength in the face of tragedy and their wish that awareness of the issue needs to be raised as widely as possible, taking into account different cultures, hard to reach groups and those not always on social media.

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