The Healthcare Safety Investigation Branch (HSIB) published its independent investigation on 27 March 2023 into the death of a three-year-old who swallowed a button battery, the Child Accident Prevention Trust (CAPT) said1. The report makes recommendations in three key areas: public awareness, product safety and clinical decision-making1.
CAPT said a button battery, particularly a powerful 3V lithium coin cell battery, stuck in a small child's food pipe creates a chemical reaction that erodes soft tissue, and can burn a hole inside the body and cause serious internal bleeding and death1. The reaction can happen in as little as two hours, and symptoms are often not obvious until it is too late1. Children between 1 and 4 are at greatest risk as they often put things they find in their mouths, and even discarded flat batteries still hold enough power to badly hurt a child1.
On product safety, the investigation found that while safety regulations require lithium coin cell batteries in children's toys to be secured in battery compartments that small children cannot access, there are no equivalent regulations for other products in homes1. CAPT said that while reputable manufacturers use child-resistant packaging, there is no requirement to do so, nor any requirement to place a warning on packaging about the consequences for a small child of swallowing a lithium coin cell battery1. The Office for Product Safety and Standards (OPSS) has commissioned BSI to develop a fast-track safety standard, called a PAS, covering battery design, product casing, packaging and safe retailing1.
On clinical decision-making, NHS call handlers now have a specific prompt on button batteries when asking questions about a child swallowing something harmful1. The report recommends that the Royal College of Paediatrics and Child Health develop a tool to support clinical decision-making, with support from the Royal College of Emergency Medicine, and suggests a study in emergency departments evaluating handheld metal detectors to scan under-fives who present with non-specific symptoms1.
"Today the Healthcare Safety Investigation Branch (HSIB) publishes its independent investigation into the death of a three-year-old who swallowed a button battery."
Why it matters for households
CAPT said too few parents know about the dangers button batteries pose or how to manage the risks1. It said lithium coin cell batteries can be found in products and gadgets, in cheap toys and novelty items, and in multi-packs of spares, and that even discarded flat batteries remain hazardous1. As part of the public awareness work, CAPT, OPSS and the British and Irish Portable Battery Association (BIPBA) launched a national safety campaign on the same day, and CAPT published a poster, "Button batteries: Where are yours?", encouraging parents to know where lithium coin cell batteries are in their homes, including in products and in spare and flat batteries, so they can keep them out of children's reach1. CAPT said it had updated its safety advice and safety flyer using insights from the HSIB report1. CAPT said it has worked on button battery safety for five years and, since 2017, in partnership with BIPBA1. The charity's guidance on flat batteries is set out in its page on flat button batteries, and general household warning information is collected in the staying informed hub.
What happens next
CAPT said it will be part of the advisory group for the fast-track PAS standard being developed by BSI1. It said it is working closely with HSIB, government and industry to make the recommendations a reality1. No date has been reported for publication of the standard or for the clinical decision-making tool.
Flat Button Battery Dangers
