Kazarie Dwaah-Lyder: Prevention of future deaths report
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Date of report: 09/02/2024
Ref: 2024-0072
Deceased name: Kazarie Dwaah-Lyder
Coroner name: Mary Hassell
Coroner Area: Inner North London
Category: Child Death (from 2015)
This report is being sent to: British Association of Paediatric Surgeons | Royal college of Paediatrics and Child Health | Royal College of Radiologists
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Consultant Paediatric Surgeon British Association of Paediatric Surgeons Royal College of Surgeons 35-43 Lincoln’s Inn Fields London WC2A 3PE 2. President Royal College of Paediatrics and Child Health 5-11 Theobald’s Road London WC1X 8SH 3. President Royal College of Radiologists 63 Lincoln’s Inn Fields London WC2A 3JW | |
| 1 | CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 12 May 2023, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Kazarie Dwaah-Lyder, aged 2½ years. The investigation concluded at the end of the inquest earlier today. I made a determination of accidental death. The medical cause of death was: 1a upper gastrointestinal bleed and haemorrhagic shock 1b oesophageal tear extending to the aorta 1c foreign body in oesophagus. |
| 4 | CIRCUMSTANCES OF THE DEATH Kazarie died as a result of swallowing a foreign body (a googly eye) in February 2022. This was investigated by x-ray and fluoroscopy at the time, but the object was not detected and he was then without symptoms for the next 14 months until his emergency admission to hospital on 26 April 2023. |
| 5 | CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. In February 2022, Kazarie was taken to hospital suspected of having swallowed a plastic foreign object. He then underwent an x-ray and a fluoroscopy, each with a negative result. It was suggested to me in evidence that children suspected of having swallowed a non radio opaque object such as a googly eye, whose symptoms (unlike Kazarie’s) persist, should undergo an endoscopy even if they have had a negative x-ray and fluoroscopy. I was told that there is a lack of national guidance for such a situation. I appreciate that there are multiple considerations in planning investigations, such as the risks associated with CT scanning and the risks associated with the administration of a general anaesthetic. It seems that the matter would benefit from consideration at a national level. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 April 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. [REDACTED], Kazarie’s mum NHS England [REDACTED], consultant radiologist, Royal London Hospital [REDACTED], consultant paediatric surgeon, Great Ormond Street Hospital for Children HHJ Thomas Teague QC, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | 09.02.24 ME Hassell |